Fld Name /
				 | 
				Instruction | 
			
A Name of Provider  | 
				Enter the complete name of the Provider on page 1.  | 
			
(a) Name of Provider  | 
				Enter the complete name of the Provider on page 7.  | 
			
(b) Signature of Provider  | 
				Enter the signature of the Provider’s authorized representative on page 7.  | 
			
(c) Title of Provider  | 
				Enter the title of the Provider’s authorized representative on page 7.  | 
			
(d) Date  | 
				Enter the date of the signature of the Provider’s authorized representative on page 7.  | 
			
	Page 
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document | 
| File Title | Instructions for CCC-576 | 
| Author | Preferred Customer | 
| File Modified | 0000-00-00 | 
| File Created | 2021-01-28 |