CGR Form for DTC docx 2025

1. Click ‘Get Form’ to open the CGR Form for DTC in the editor.
2. Begin by entering the Insured’s Name, Policy Number, and Claim Number in the designated fields. Ensure accuracy as this information is crucial for processing.
3. In Section I, provide the Independent Care Provider Information. Fill in the Provider’s Name, Relationship to Insured, Date of Birth, and select the Type of Care Provider from the options available.
4. Next, input the Shift Rate and complete the Provider’s Home Address details including City, State, ZIP Code, and Email Address. Don’t forget to include the last four digits of their Tax ID or SSN.
5. For Section II, specify the Type of Identification being provided along with its ID Number and Expiration Date. This is essential for verification purposes.
6. Review Section III regarding Fraud Notice carefully before signing. Finally, ensure that you sign and date at the bottom of the form to validate it.

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