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Click ‘Get Form’ to open the CF-4 in the editor.
Begin by entering the name under which your corporation was authorized to transact business in West Virginia in the first field.
In the second field, provide the date when your Certificate of Authority was issued in West Virginia.
If your corporate name has changed, indicate the new name in the designated section and attach a certified copy of the name change from your home state.
If necessary, specify a 'forced DBA Name' if your desired name is unavailable, and attach a Letter of Resolution signed by your corporation's officers or directors.
Fill out any additional amendments in the provided space, attaching extra pages if needed.
Optionally, include a contact person's name and phone number for any follow-up regarding your filing.
Finally, complete the signature section by printing the signer's name, title, signing, and dating the form. Ensure compliance with legal notice requirements.
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Claim Form 4 or CF4 is the summary of pertinent clinical information of a patient/member during their hospitalization/episode of care that shall be utilized by PhilHealth to conduct evaluation and review of Claims. It is an additional claim application requirement for case rate claims.
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