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 Pioneer Valley Billing

Provider:

Patient Name:

Authorization Number:

Number of Sessions Authorized:

Date Range of Sessions Authorized: to

For Authorizations Call: extension:

Authorization Fax:

Please fill out form and Fax to (413) 238-5860 •

Pioneer Valley Billing - 74 Thrasher Hill Road, Worthington, MA 01098
Phone: (413) 552-9275 • Fax (413) 238-5860 • E-Mail: pioneervalleybilling@protonmail.com