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I,egal Practice Name: <br />(as it appears on W-9 form) v I L. L q G. 6' p F m AY t= m- ` D <br />Primary Practice Address: +T 9 1) 9, 0, ni , C C NT C Q rZ 0 AD <br />M A y F ir L D V i L L. AG-z= Dff y y/ 5?3 <br />Tax Identificanon Number: C) O/ 4 <br />"Name of person sigaing contract: <br />(PRINTED) D? v c - rn Q H R <br />Title: e H / r 1-- <br />"This name should be the person who signs all contracts for your group. <br />By signing this form, I agree that the information entered above is complete and accuYate. I <br />acknowledge that this anfoYmation will be used by Anthem Blue Cross and Blzae Shield (flnthem) <br />as part of the contf-acting process. Any inaccuYacies identified will result in a replacement <br />contract, and a delayed effective date I also recognize that no contracts will be mailed by <br />Anthem zcntil this form is received by ovideY Relations. <br />Sio a cre Date <br />Title <br />Please return this completed form to: <br />Cleveland Provider Relations <br />An#hem BIue Cross and Biue Shield <br />8333 Rockside Road, Sui#E 200 <br />Cieveland, OH 44125 <br />flr fax: 29 6a573-4615 <br />pnin?:i«asmoFth&ucCmss=d8lae5SiddtwodaricaAnthem&xQ? audBlucSSidd'u;hetadeoameoFCemmuviry7asncameCcmpany.aRegiuav4mazl¢&ueC:essmdMe56ietdAoocriou. Ravisej09/05.