Social Security Number Employee Date of Hire: Job Title: Employee D.O.B: Name of Cost Center working for Race of Employee (two part question):
Social Security numbers The Contractor agrees to comply with all applicable Vermont State Statutes to assure protection and security of personal information, including protection from identity theft as outlined in Title 9, Vermont Statutes Annotated, Ch. 62.
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: Fax: Contact Person: Email Address: 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. Revised 04/13/2018 Network Provider Home Health Care Agency Contract Signature Page The Office of Management and Enterprise Services Employees Group Insurance Division (EGID), and the Facility incorporated by reference the terms and conditions of the HealthChoice Network Facility Contract (Contract) located in HCHHCv2.1 at xxxx://xxxx.xx.xxx/services/healthchoice/providers/contracts-and- applications into this Signature Page and acknowledge the Contract is an electronic record created according to 12A O.S. § 15-011 et seq. 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: FOR EGID: Legal Name of Owner (Typed or Printed) Xxxxx X’Xxxx Deputy Administrator Employees Group Insurance Division Trade Name/DBA (Typed or Printed) Federal Tax ID Number Address of the Facility: Authorized Officer or Representative (Typed or Printed) Title Signature Signature Date 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
Mobile Number means a Telephone Number, from a range of numbers in the National Telephone Numbering Plan, that is Adopted or otherwise used to identify Apparatus designed or adapted to be capable of being used while in motion;
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.
CT number means the number used to represent the x-ray attenuation associated with each elemental area of the CT image.
Charge Number means the CCS signaling parameter that refers to the number transmitted through the network identifying the billing number of the calling Party.
Identifying number means a symbol or address that identifies only one unit in a common interest community.
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.
Calling Party Number or "CPN" is a Common Channel Signaling (CCS) parameter which refers to the ten digit number transmitted through a network identifying the calling party. Reference CenturyLink Technical Publication 77342.
Project Number means a unique number assigned to the project by the department or the city, village, town or county that is undertaking the project.
CAS number means the Chemical Abstract Service registry number identifying a particular substance.
Mobile Phone Number means the Mobile Phone number which We hold with Our contact details for You or as notified by You to Us in accordance with Condition 2(d) below.
Caller identification service means a service that allows a telephone subscriber to have the telephone number, and, where available, name of the calling party transmitted contemporaneously with the telephone call, and displayed on a device in or connected to the subscriber’s telephone.
Data Universal Numbering System+4 (DUNS+4) number means the DUNS number means the number assigned by D&B plus a 4-character suffix that may be assigned by a business concern. (D&B has no affiliation with this 4-character suffix.) This 4- character suffix may be assigned at the discretion of the business concern to establish additional SAM records for identifying alternative Electronic Funds Transfer (EFT) accounts (see the FAR at Subpart 32.11) for the same concern.
Account Number means the identification number given by the U.S. EPA to each NOx allowance tracking system account.
Name The Bank of New York Address: Xxx Xxxxxx Xxxxxx Xxxxxx X00 0XX Facsimile Number: 020 7964 6061/6399 Attention: Global Structured Finance
Email Address means a current valid email address.
Personal Identification Number (PIN) means a confidential four-digit code number provided to a calling card customer to prevent unauthorized use of his/her calling card number. LIDB and/or the LIDB administrative system can store a PIN for those line numbers that have an associated calling card.
Contract Number means, with respect to any Contract included in the Trust, the number assigned to such Contract by the Servicer, which number is set forth in the related Schedule of Contracts.
Relevant Number means the number specified as such in the applicable Final Terms (or, if no such number is specified, five);
Unit number means the number, letter, or combination of numbers and
Residential address means the physical location where the student’s parents, legal guardians, persons having legal, lawful control of the student under order of a court, or persons standing in loco parentis reside. A student may use the residential address of a legal guardian, person having legal, lawful control of the student under order of a court, or person standing in loco parentis only if the student resides at the same residential address and if the guardianship or other legal authority is not granted solely for educational needs or school attendance purposes.
Item number means the unique number attached to each professional service contained in the Medicare Benefits Schedule (MBS). Each item number has a set benefit. For more information see MBS Online.
Original part number means a combination of numbers or letters assigned by the enterprise at item creation to a class of items with the same form, fit, function, and interface.
Provider Number means an identifying number issued to each homecare worker who is enrolled as a provider through the Department.