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Copy Existing Submitted Application
Thursday 11/21/2024 03:28 AM CST
Provider Enrollment: Copy Existing Submitted Application
Enter your assigned Tracking Number, Tax ID and Password in order to copy an existing provider enrollment application. For further questions, please contact Provider Services at 1-800-884-3222.
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Tracking Number
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The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"/].
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Tax ID
Tax ID is a required field.
Tax ID is not valid or in the correct format. Enter a valid value in the format '999999999'.
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Password
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