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Please complete & submit via fax to 877PDB6173 (877732

877-732-6173

CCM – CSI_RC_TeamCare_Medical_Predetermination.pdf – 6/7/2021 MEDICAL PREDETERMINATION OF BENEFITS REQUEST FORM* Please complete & submit via fax to 877-PDB-6173 (877-732-6173)

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Maryland / Contact Change Request / Individual & Business

(888) 204-6198

Submit contact change request for any license on NIPR's Producer Database (PDB) Phone: (888) 204-6198 Fax: (410) 468-2399 How do entities update contact information? Update Contacts; 1100 Walnut Street, Suite 1500 Kansas City, MO 64106

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