Provider Information. BCBSM may disclose Provider specific information as follows:
Provider Information. (1) The MCO must submit annually by April 15th of the Contract Year a complete list of Participating Providers, including name, specialty, and address, in a format approved by the STATE using a current version of Excel. For MSHO, providers of Medicare and Medicaid services must be included. The MCO shall also submit an update of its list of Participating Providers, in the same format, by the 15th day of October of the Contract Year. (Note: this excludes pharmacies, transportation providers, and interpreters.)
Provider Information. Avesis shall make available to Members through the Avesis website and/or the Sponsor’s website or through a toll-free customer service telephone number the names, addresses, phone numbers and specialties of all Providers who agree to participate under each Sponsor’s plan.
Provider Information. All services will be furnished in full compliance with the non-discrimination requirements of Title VI of the Federal Civil Rights Act, Section 504 of the Rehabilitation Act of 1973 and the Standards of Privacy of Individual Identifiable Health Information, the Electronic Transactions Standards and the Security Standards under the Health Insurance Portability and Accountability Act of 1996 as enacted, promulgated and amended from time to time. I understand that payment and satisfaction of all claims will be from Federal and State funds and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws, or both.
Provider Information. Provider agrees that now and hereafter Blue Shield may utilize, publish, disclose and display information relating to Provider and/or to the Agreement to entities, including, but not limited to, current and potential group customers and their agents or designees, the Blue Cross and Blue Shield Association and its related plans, participating providers, and current and potential members, using those formats and media (including, without limitation, marketing materials, other publications, directories and internet) that are most appropriate under the specific circumstances, such information to include, but not be limited to, Provider’s name, address and telephone number; description of Provider’s services; descriptive and educational information, including the results of customer satisfaction surveys concerning Provider and its services, facilities and staff; information relating to Provider’s costs, charges, payment rates and/or amounts for services hereunder, patient pay amounts (including coinsurance amounts), quality, utilization, and data relating to Provider’s delivery of health care; and any data, information and conclusions generated in connection with a Blue Shield designed program, report and/or study regarding Provider and/or other participating providers.
Provider Information. A. The following affiliates and subsidiaries of Provider are incorporated into this Agreement:
Provider Information. Provider Name* Complete legal name of institution, corporate entity, practice or individual provider. Doing Business as Name (DBA) A legal term used in the United States meaning that the trade name, or fictitious business name, under which the business or operation is conducted and presented to the world is not the legal name of the legal person (or persons) who actually own it and are responsible for it.
Provider Information. NOTE: THIS INFORMATION SHOULD ONLY BE THE INFORMATION OF A NEW JERSEY MEDICAID PROVIDER. IF YOU ARE A SECONDARY BILLING SERVICE, PLEASE ADD A SUPPLEMENTARY SECTION 3 AND PLACE BILLING SERVICE INFORMATION ONLY IN SECTION 3.
Provider Information. Provider’s Name Date of Birth PS Number Address Mailing Address (if different): Will the Provider be claiming Xxxxxxxx’s own children? Yes No NA Any changes in Provider Information require a Change in Information Form. Provider Initials SECTION II: Business Information Facility license: PV Number: Business Name: Address: Expiration date: Email: Telephone: Mailing Address (if different): Days of operation (circle): Sun. Mon. Tues. Wed. Thurs. Fri. Sat. Business hours: am pm Meals Meals Served Meals Claimed Meal Start Time 2nd Meal Shift Breakfast □ □ am/pm am/pm AM Snack □ □ am/pm am/pm Lunch □ □ am/pm am/pm PM Snack □ □ am/pm am/pm Supper □ □ am/pm am/pm Evening Snack □ □ am/pm am/pm Any changes in Business Information require a Change in Information Form. Provider Initials CNP:/!Sponsoring Organizations/Sponsor Forms/FY17 Sponsor Provider Agreement REVISED 11/21/2016
Provider Information. The State will provide the Union with a list of Family Childcare Providers electronically on a monthly basis by the fifth (5th) business day of each month. This list will include:
