Test Reimbursement

    Provider Information

    Billed Sessions

    Electronic Signature Agreement

    I certify, to the best of my knowledge, that all information in this request is true and accurate. I understand that all billed sessions are subject to verification and approval by Tri-County Health Network.

    The parties agree that this agreement may be electronically signed. The parties acknowledge that electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

    (Use your mouse or trackpad to sign.)

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