INDIVIDUAL PROVIDER Sample Clauses
INDIVIDUAL PROVIDER. I understand that payment of claims will be from federal and state funds and that any falsification or concealment of a material fact may be prosecuted under federal and state law. Printed Name of Individual Practitioner: Signature of Individual Practitioner: Date:
INDIVIDUAL PROVIDER. I understand that payment of claims will be from federal and state funds and that any falsification or concealment of a material fact may be prosecuted under federal and state law.