Common use of INDIVIDUAL PROVIDER Clause in Contracts

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. Printed Name of Individual Practitioner: Signature of Individual Practitioner: DateDate FOR STATE PURPOSES ONLY: HUMAN SERVICES DEPARTMENT APPROVAL APPROVED NOT APPROVED Reasons Not Approved: Dates of Agreement: From: