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Register or Cancel a Service Provider

: Please complete this form to register or cancel a Service Provider. By registering a Service Provider you are agreeing that they may submit a claim form for services provided to you. It is your responsibility to cancel a registration. If there are insufficient funds, accounts will be forwarded to members for direct payment.
Member:
Please provide your instructions by checking the appropriate box:: Register the following Service ProviderCancel the following Service Provider
Service Provider:
Address:: Line 1:
Line 2:
City:
Country:
State:
Postal Code:
Telephone:
Email Address: