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Step 1 of 4
Please use the "Previous" and "Next" buttons below to review the form in its entirety and provide your name below as your digital signature prior to submitting this invoice. By signing your name below, you are digitally signing this invoice. This form must be submitted within forty-five (45) days of the last date of service to be eligible for reimbursement. Please make sure to check your entries before hitting the submit button. Please print the screen to keep a copy for your records.
By clicking “Submit” you acknowledge and agree that you have already entered into a Business Associate Agreement (“BAA”) with Workplace Solutions. This Submission is a permitted disclosure as set forth in Section 2 of the BAA because you are using and/or disclosing any applicable PHI merely to comply with proper management and administration, and all information submitted will be held confidentially and used only as required by law or for purpose for which it was disclosed.
New Affilate Application.pdf