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["Required field*",null,"Church plan, ERISA group health plan (GHP), (Non-Federal) governmental group health plan, or Health insurance issuer/insurer","Only applies to ERISA group health plans and sponsors of ERISA group health plans","Date range covered by the attestation for each Responsible Entity",null,"Responsible Entity Information",{"$nulls":3},"If attesting for all of the plan's or issuer's provider agreements, place a Y in the cell below","If attesting for a specific type(s) of provider agreement only, place a Y 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 L - N, list them in the cell below, separated by a semi-colon.","*Either Column K must be marked with a Y or one of the following: at least one of columns L-N must be marked with a Y and/or column O must identify one or more provider agreement types."]
["Name of Responsible Entity*","Employer Identification Number (EIN)*","Responsible Entity Type*","Plan Number","Start Date \n(mm-dd-yyyy)*","End Date \n(mm-dd-yyyy)*","Mailing Address for the Responsible Entity*","Name of Responsible Entity's Point-of-Contact*","E-mail Address for Responsible Entity's Point-of-Contact*","Phone Number for Responsible Entity's Point-of-Contact*","Attestation is for All Provider Agreements","Medical network","Pharmacy benefit manager network","Behavioral health network","Other Type(s) of Provider Agreement(s)"]