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["Required field*",null,"Health Insurance Issuer, non-Federal Governmental Plan, ERISA Plan (or Sponsor of ERISA Plan), or Church Plan","Only applies to ERISA plans and sponsors of ERISA plans",{"$nulls":3},"Column I or one or more of columns J-M must be marked with an X","If attesting for all types of provider agreements, place an X in the cell below","If attesting for a specific type(s) of provider agreement only, place an X below in the applicable cells of the column(s) that apply; otherwise leave the column blank",null,null,"If attesting for a specific type(s) of provider agreement(s) other than or in addition to those in columns \nJ - L, list them in the cell below"]
["Name of the Reporting Entity* ","Employer Identification Number (EIN)*","Reporting Entity Type*","Plan Number","Mailing Address for the Reporting Entity*","Name of Reporting Entity Point-of-Contact*","E-mail Address for Reporting Entity Point-of-Contact*","Phone Number for Reporting Entity Point-of-Contact ","Attestation is for All Provider Agreements","Medical","Pharmacy Benefits","Behavioral Health","Other Type(s) of Provider Agreement(s)"]