Field 2: BILLING SERVICE NAME If applicable, enter the name of the billing service that the provider is enrolled. with. If you are not using a billing service, leave this field blank. Field 3: DATE Enter the date the Certification Statement is submitted to the fiscal agent.
Gregory Jerome Coleman (born September 9, 1954 in Jacksonville, Florida) is a retired American football punter who had a 12-year career in the National Football League playing for the Cleveland Browns, the Minnesota Vikings, and the Washington Redskins. He attended Florida A&M University.
Coleman's agent, Mark Bloom, issued the following statement to KOMO News on Thursday: On the evening of October 15, 2015, Seattle Seahawk Fullback Derrick Coleman, Jr. was involved in a two-car collision soon after leaving a team meeting.