Berkleyentertainment.com

Medical Bill Submission

WEBTo speak to a live agent, call (608) 373-6255 or 1 (888) 996-9903. * Hours (Central) Monday-Friday 6:00 am – 6:00 pm. * Answering service available outside of business hours. Website: https://datadimensions.com. Workers’ Compensation Medical Provider Electronic Bill Submissions. If your organization is connected to the Jopari Clearing House

Actived: 1 days ago

URL: https://www.berkleyentertainment.com/medical-bill-submission/

WORKERS' COMPENSATION

WEBApplicable in Minnesota: Any person who, with intent to defraud, receives workers’ compensation benefits to which the person is not entitled by knowingly misrepresenting, misstating, or failing to disclose any material fact is guilty of theft and shall be sentenced pursuant to s 609.52, subdivision 3.

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CAST MEDICAL FORM

WEBCAST MEDICAL FORM. I affirm that I am the examinee named above: that the statements made hereon by me are true, correct and complete; that I have withheld no information known to me which might alter or otherwise conflict with the statements made by me. I understand that the insurer will hold me personally liable and will seek recoupment from

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A COPY OF THIS AUTHORIZATION IS AS VALID AS THE …

WEBGreat Divide Insurance Company c/o Berkley Entertainment P.O. Box 141299 Irving, TX 75014-1299 Email: [email protected] Fax: (866) 826-3862. My revocation will be effective upon receipt by "Insurer", except to the extent that "Insurer" or their authorized agents have already acted in reliance upon this Authorization.

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CAST MEDICAL FORM

WEB4. Will you be performing any special physical activities in this production (e.g. running, climbing, weapon work, fight sequences, aerial, etc.)?

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To Our Insurance Customers and Agents and Brokers

WEBTo Our Insurance Customers and Agents and Brokers: In these unprecedented and difficult times, the COVID-19 pandemic has impacted businesses, employees, customers and communities.

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