PO BOX 2368 CORNELIUS NC 28031 XXXXXXXXX - Health Network Solutions
DOE JOHN A 123 ANY STREET ANYTOWN
00000
HNS/ HTA PO BOX 2368 CORNELIUS NC 28031
01 01 1950 X X
US
X X X
XXXXXXXXX DOE JOHN A
123 ANY STREET
ANYTOWN
US
00000
HTA
HEALTH TEAM ADVANTAGE
01 01 20
0
M99.03
M99.02
10 15 20 10 15 20 11
98940 AT
AB
50 00 1
0000000001
01- 0000001
X
JOHN Q CHIROPRACTOR DC
DOE1234
X
CHIROPRACTOR'S OFFICE 123 ABC STREET ANYTOWN, US 00001 0000000002
PLEASE PRINT OR TYPE
50 00 001 001-0001
JOHN Q CHIROPRACTOR DC PO BOX 000 ANYTOWN US 00001 0000000002
APPROVED OMB-0938-1197 FORM 1500 (02-12)
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