Phone Number Email Address: (Please Print) ______________________________________ ______________________________________ Dated: _______________ __, ______ Holder’s Signature: Holder’s Address:
Charge Number means the CCS signaling parameter that refers to the number transmitted through the network identifying the billing number of the calling Party.
Telephone Number Email Address:
Fax Number Email Address: Credentialing Contact: Telephone Number: Fax Number: Email Address: Address Information Federal Tax ID Number: National Provider Identification: Attach a completed W9 form for each Federal Tax ID number. Physical Address – physical location of the Facility THIS ADDRESS AND PHONE NUMBER WILL APPEAR ON THE WEBSITE PROVIDER DIRECTORY. Physical Address: Mailing Address Mailing Address: City State ZIP Phone: Fax: Contact Person: Email Address: Mailing contact information, if listed, will be utilized for all legal, contractual notices as defined in section 11.2 or 12.2 of the facility contracts. An email address must be included for this contact in order to access the online fee schedules. All notices will be sent electronically. Billing/Remit Address – for claims payments and remittance statements ALL BILLING INFORMATION BELOW MUST MATCH THE INFORMATION REFLECTED ON THE CLAIMS SUBMITTED. Name Submitted on Claims: Billing Office Name (if applicable): Billing Address: City State ZIP Phone: Contact Person: Email Address: Fax: Additional Location Federal Tax ID Number: National Provider Identification: Attach a completed W9 form for each Federal Tax ID number. Physical Address – physical location of the Facility THIS ADDRESS AND PHONE NUMBER WILL APPEAR ON THE WEBSITE PROVIDER DIRECTORY. Physical Address: Mailing Address- for correspondence/credentialing Mailing Address: City State ZIP Phone: Fax: Contact Person: Email Address: Billing/Remit Address – for claims payments and remittance statements ALL BILLING INFORMATION BELOW MUST MATCH THE INFORMATION REFLECTED ON THE CLAIMS SUBMITTED. Name Submitted on Claims: Billing Office Name (if applicable): Billing Address: City State ZIP Phone: Fax: Contact Person: Email Address: Please use copies of these pages to report any additional locations. Network Provider Laboratory Contract Signature Page The Office of Management and Enterprise Services Employees Group Insurance Division (EGID), and the facility incorporate by reference the terms and conditions of the Network Facility Contract into this signature page. EGID and the facility further agree that the effective date of the contract is the effective date denoted on the copy of the executed signature page returned to the facility. The original of the signed document will remain on file in the office of EGID. FOR THE FACILITY: Legal Name of Owner (Typed or Printed) Trade Name/DBA (Typed or Printed) Federal Tax ID Number Address of the Facility: Authorized Officer or Representative (Typed or Printed) Title Please return the completed Application, Signature Page, and required attachments to: Office of Management Enterprise Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 Oklahoma City, OK 73112 Phone: 000-000-0000 or 000-000-0000 Fax: 000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx Signature Signature Date FOR EGID: Xxxx X. Xxxx Deputy Administrator Employees Group Insurance Division
License number means the official number issued to a private security services business licensed by
Requisite Number means 500, and
FX Telephone Numbers means those telephone numbers with rating and routing point that are different from those of the geographic area in which the End User is physically located. FX Telephone Numbers that deliver second dial tone and the ability for the calling Party to enter access codes and an additional recipient telephone number remain classified as Feature Group A (FGA) calls, and are subject to the originating and terminating carrier’s tariffed Switched Exchange Access rates (also known as “Meet Point Billed” compensation).
Automatic Number Identification or "ANI" means a Feature Group D signaling parameter which refers to the number transmitted through a network identifying the billing number of the calling party.
DUNS Number means a unique nine digit identification number provided by Dun & Bradstreet for each physical location of Grantee’s organization. Assignment of a DUNS Number is mandatory for all organizations seeking an Award from the state of Illinois.
Identifying number means a symbol or address that identifies only one unit in a common interest community.
File number means the number assigned to an
Data Universal Numbering System (DUNS) number means the 9-digit number assigned by Dun and Bradstreet, Inc. (D&B) to identify unique business entities.
Delivery Address means the address stated on the Order.