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REQUEST FOR INFORMATION

• Request for information is also available in Portable Document Format (PDF, 20KB, 1pg.)

RETURN TO:

Regular Mail: Mr. Jerome Alaimo, Pool Administrator
Office of Pool Administration
Excellus BlueCross BlueShield
Central New York Region
P.O. Box 4757
Syracuse, NY 13221-4757

Express/Overnight Mail:
Mr. Jerome Alaimo, Pool Administrator
Office of Pool Administration
Excellus BlueCross BlueShield
Central New York Region
333 Butternut Drive
Syracuse, NY 13214-1803

FAX: (315) 448-6786

FROM:

Hospital: ________________________________________________________________

CFO: ___________________________________________________________________

SUBJECT: Electronic Filing of Bad Debt and Charity Care Accountant's Report

PLEASE PRINT OR TYPE THE INFORMATION BELOW:

CFO Name: ______________________________________________________________

CFO´s E-mail address: ______________________________________________________

Hospital Name: ___________________________________________________________

Hospital Opcert: __________________________________________________________

Hospital Address:
_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

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