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Medical Claims Resources 5962 NW 77th Drive, Parkland, FL 33067 (954) 755-7870 Fax (954) 755-6856 Prepayment Required
Method of payment: [ ] Check enclosed [ ] Visa [ ] Master Card [ ] American Express Credit card_____________________________________________ Exp date: _______________________ Cardholder name: _________________________________________________________________ Company:________________________________________________________________________ Name:__________________________________________________________________________ Address:________________________________________________________________________ Phone:_____________________________________ Fax: _______________________________ | ||||||||||||||||||||||||||||||||||||||||||||