Common use of Signature Block Clause in Contracts

Signature Block. If Provider is a legal entity other than a person, identify the organization in the first line of the signature block. The person signing this Core Provider Agreement on behalf of the Provider warrants that he/she has legal authority to bind Provider. PROVIDER LEGAL ENTITY NAME SIGNATURE OF PROVIDER OR OWNER/MANAGER TITLE DATE FULL NAME (PRINTED) NPI PROVIDER SPECIALTY For additional information on Provider Enrollment go to: xxxx://xxx.xx.xxx/billers-providers/apple-health-medicaid-providers/enroll-provider Questions? Toll-Free 1-800-562-3022, ext. 16137

Signature Block. If Provider is a legal entity other than a person, identify the organization in the first line of the signature block. The person signing this Core Provider Agreement on behalf of the Provider warrants that he/she has legal authority to bind Provider. PROVIDER LEGAL ENTITY NAME SIGNATURE OF PROVIDER OR OWNER/MANAGER TITLE DATE FULL NAME (PRINTED) NPI PROVIDER SPECIALTY For additional information on Provider Enrollment go to: xxxx://xxx.xx.xxx/billers-providers/apple-health-medicaid-providers/enroll-provider xxxx://xxx.xxx.xx.xxx/medicaid/providerenroll/pages/enroll.aspx#provider Questions? Toll-Free 1-800-562-3022, ext. 16137