Items A-E
| 
					Fld Name / | Instruction | 
| A Name of Provider | Enter the complete name of the Provider. | 
| B Name of Provider | Enter the complete name of the Provider. | 
| C Signature of Provider | Enter the signature of the Provider’s authorized representative. | 
| D Title of Provider | Enter the title of the Provider’s authorized representative. | 
| E Date | Enter the date of the signature of the Provider’s authorized representative. | 
	 
		
| File Type | application/msword | 
| File Title | Instructions for CCC-665 | 
| Author | Preferred Customer | 
| Last Modified By | Judy.Fry | 
| File Modified | 2008-04-24 | 
| File Created | 2008-04-24 |