Bill Only Form

Note: No patient information/PHI should be transmitted utilizing this form.
I have read, acknowledge and agree to the SHS vendor management policy letter. I have also checked all product identified for any outdates/expirations.
One file only.
50 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
One file only.
25 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
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