Examples of Medicaid Number in a sentence
NAME OF PROVIDER Attn: Signature Print Name Title Date Federal Tax ID Number: Medicare Number: Medicaid Number: NPI Number: UNITED BEHAVIORAL HEALTH PROVIDER AGREEMENT Kansas Regulatory Requirements Attachment This Kansas Regulatory Requirements Attachment (the “Attachment”) is made part of this Agreement entered into between United Behavioral Health (“UBH”) and the health care professional named in this Agreement (“Provider”).
The child is insured by the following health or accident insurance policies: Name of Company Location of Branch Office Contract or Policy Number or Medicaid Number If the above coverage changes at any time, I/we will immediately inform Teaching-Family Homes of Upper Michigan.
Yes or No Medicaid Number: I HEREBY AUTHORIZE PAYMENT OF MEDICAID BENEFITS TO AUBURN CITY SCHOOLS DENTAL CLINIC.
Yes No Provider Name* NPI Number (Individual Type 1)* Provider Email Address Washington State License Number* Medicaid Number (if applicable) Sedation Conscious Ped.
Languages Spoken Fluently: Last First MI - - Owner Partner Associate Medicaid Number: _ / / _ _ Male Female YES (Submit copy) NO (Complete statement below) IF PENDING COMPLETE: I Dr. _ will not write prescriptions until I have received my current Federal DEA.
Date: Resident’s Signature or Mark or Designated Representative: Medicaid Number: Signature of Witness: Printed Name of Witness: Fishkill Center for Rehabilitation and Nursing Photographing, Videotaping, or Other Recordings Consent and Release Form Name of resident D.O.B Unit A.
Tax Identification Number: State Medicaid Number: CCHN: Carolina Complete Health Network, Inc.
Provider’s Medicaid Number issued for Intensive In-Community Therapy /Behavioral Assistance is If Provider’s Medicaid application is in process, please provide the date that application was submitted: Provider understands that it is Provider’s responsibility to clarify the Medicaid eligibility of the person referred for service before providing any service.
Xxxxxxxxxxx Title: Vice President, Network Development & (Legibly Print Name of Provider) Authorized Signature: Print Name: Title: Contracting Signature Date: ECM #: Signature Date: Tax Identification Number: To be completed by Health Plan only: Effective Date: State Medicaid Number: National Provider Identifier: PARTICIPATING PROVIDER AGREEMENT SCHEDULE A CONTRACTED PROVIDER-SPECIFIC PROVISIONS Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A.
State Medicaid Number: CCHN: Carolina Complete Health Network, Inc.