HCS Member Sample Clauses

HCS Member. Any patient referred by Hearing Care Solutions to a participating provider is considered an HCS patient regardless of the originating health plan. Participating providers are required to service all patients referred by HCS regardless of health plan affiliation. Reverse Referrals for HCS contracted health plans are also HCS patients. Location Name: HCS Location ID: Office Contact: Location Address: Bank Name: Bank Address: Bank State & Postal Code: Bank Telephone Number: Routing Number: Account Number: This banking information is for multiple offices: Yes No Location Name: HCS Location ID: Office Contact: Location Address: HCS Location ID: Office Contact: Location Address: Please add additional pages as necessary. Return this form to xxxxxxxxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx . Form W-9 (Rev. December 2014) Department of the Treasury Internal Revenue Service See Specific Instructions on page 2. 3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4 Exemptions (codes apply only to Individual/sole proprietor or single-member LLC C Corporation S Corporation Partnership Trust/estate certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) a Other (see instructions) a Exemption from FATCA reporting code (if any)

HCS Member. Any patient referred by Hearing Care Solutions to a participating provider is considered an HCS patient regardless of the originating health plan. Participating providers are required to service all patients referred by HCS regardless of health plan affiliation. Reverse Referrals for HCS contracted health plans are also HCS patients.