Items A-E
| 
					Fld Name / | Instruction | 
| A Name of Provider | Enter the complete name of the Provider. | 
| (a) Name of Provider | Enter the complete name of the Provider. | 
| (b) Signature of Provider | Enter the signature of the Provider’s authorized representative. | 
| (c) Title of Provider | Enter the title of the Provider’s authorized representative. | 
| (d) Date | Enter the date of the signature of the Provider’s authorized representative. | 
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document | 
| File Title | Instructions for CCC-665 | 
| Author | Preferred Customer | 
| File Modified | 0000-00-00 | 
| File Created | 2021-02-01 |