Disclosure of ownership and control interest bcbs il Form 2024

Disclosure of ownership and control interest bcbs il Form: What You Should Know

Provider Disclosure of Ownership and Control Interest Form If Yes, I certify that the above information is true and correct to the best of my knowledge as of the date  set forth below. 3)  Physician Certification (Physician, Physician Assistant, Surgeon, Nurse, Physician)  I hereby certify that the information provided is true and correct to the best of my knowledge as  of the date set forth below. 4)  Provider Disclosure of Ownership and Control Interest Form My name is: _______________ (name and address of disclosing entity) I certify that the following information is true and correct to the best of my knowledge as of the date  set forth below. I have read the disclosures on this form. 5) Physician Certification (Physician, Physician Assistant, Surgeon, Nurse, Physician) I hereby certify that the information provided is true and correct to the best of my knowledge as of the date  set forth below. I have read the disclosures on this form. 6)  Physician Certification (Physician, Physician Assistant, Surgeon, Nurse, Physician) Physician Certification (Physician, Physician Assistant, Surgeon, Nurse, Physician) I hereby certify that the information provided is true and correct to the best of my knowledge as of the date set forth below. 7)  Physician Certification (Physician, Physician Assistant, Surgeon, Nurse, Physician) Physician Certification (Physician, Physician Assistant, Surgeon, Nurse, Physician) I hereby certify that the information provided is true and correct to the best of my knowledge as of the date set forth below. 8)  Physician Certification (Physician, Physician Assistant, Surgeon, Nurse, Physician) Physician Certification (Physician, Physician Assistant, Surgeon, Nurse, Physician) I hereby certify that the information provided is true and correct to the best of my knowledge as of the date set forth below.

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