Provider Guide - the Culinary Health Fund
Provider Guide - the Culinary Health Fund
Provider Guide - the Culinary Health Fund
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1901 Las Vegas Blvd. So.<br />
Suite 101<br />
Las Vegas, Nevada 89104-1309<br />
(702) 892-7313<br />
www.culinaryhealthfund.org<br />
ALLOWABLE AMOUNT REQUEST FORM<br />
<strong>Provider</strong> Name<br />
TIN<br />
Please enter CPT procedure codes in each cell and fax your request to <strong>Provider</strong> Services<br />
(702) 892-7326. Please include your contact information and fax number on <strong>the</strong> cover<br />
page.<br />
The allowables requested are not a guarantee of payment. <strong>Provider</strong> shall be reimbursed<br />
according to <strong>the</strong> terms of <strong>the</strong>ir contract. Any reimbursement shall be subject to applicable<br />
modifier reductions, co-pays, deductibles, co-insurance, plan limitations, exclusions and<br />
nationally accepted coding initiatives.
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