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Workers' Compensation
Provider Notification Form

As we strive to maintain a strong network that will meet your business needs, please help us identify all medical providers and facilities you would like to see become a part of The First Health Network.  To proceed, we must have the name of the provider, address, phone number, and tax identification number.  If you have any questions regarding this process, please call Lynn McWhite at 864-240-5843 or e-mail lmcwhite@hewittcoleman.com.

Provider/Practice Name Address 
City
State 
Zip 
Phone No 
Tax ID No 
Nominated By
Company 
E-Mail 

       

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