Information for Providers. Contracted Provider shall provide the following information for (1) Contracted Provider, (2) each other Provider and (3) each of their respective medical facilities: - Name - Address - E-mail address - Telephone and facsimile numbers - Professional license numbers - Medicare/Medicaid ID numbers - Federal tax ID numbers - Completed W-9 form - National Provider Identifier (NPI) numbers - Provider Taxonomy Codes - Area of medical specialty - Age restrictions (if any) - Area hospitals with admitting privileges (where applicable) - Whether Providers are employed or subcontracted with Contracted Provider using the designation “E” for employed or “C” for subcontracted. - For a subcontracted Provider, whether its Providers are employed or contracted with the subcontracted Provider using the designation “E” for employed or “C” for contracted. - Office contact person - Office hours - Billing office - Billing office address - Billing office telephone and facsimile numbers - Billing office email address - Billing office contact person ATTACHMENT B PROGRAM ATTACHMENTS (See following attachments) ATTACHMENT B-1 NORTH CAROLINA MEDICAID PROGRAM ATTACHMENT
Information for Providers. The MCO must provide all providers and subcontractors upon entering into a contract with the Plan, the same information pertaining the Plan’s grievance, appeal and fair hearing procedures as was provided to enrollees as described in this section of this contract.
Information for Providers. Please note the following conditions apply to this Framework:
Information for Providers. Relationship to child: This declaration is your evidence of claim and must be retained for 7 years to complete headcount forms and for future reference, including auditing. Please note that you may be asked by the authority to produce evidence of a claim at any time. When a child who is or becomes eligible for Free Entitlement Funding registers with your provision, you must obtain proof of eligibility. Please indicate which documents have been seen by ticking the relevant box below. Birth Certificate Passport Position: __ Signature: Date: Ethnicity Codes: Code Description Code Description Code Description ABAN Bangladeshi CHNE Chinese WIRI White - Irish AIND Indian MOTH Any other mixed background XXXX Traveller of Irish Heritage AOTH Any other Asian background MWAS White and Asian WOTH Any other White background APKN Pakistani MWBA White and Black African WROR Gypsy/Roma BAFR Black-African MWBC White and Black Caribbean REFU Refused BCRB Black OOTH Any other ethnic group BOTH Any other Black background WBRI White - British Residency Codes: (the authority you pay your Council Tax to) Code Authority Code Authority Code Authority Code Authority B B&NES H Hampshire SG South Glos W Wiltshire D Dorset O Oxfordshire SW Swindon M Military G Gloucestershire S Somerset XX Xxxx Berkshire Other Other (please state) Appendix 3 Provider Name : Bumble Bees Nursery URN :123456 Contact Person : Mr Bumble Claim for Free Entitlement Funding Headcount Form – Summer 2016 (2–6 May 2016) Please draw a line through those children listed that you no longer wish to claim funding for. Please use black ink only and do not use tippex. Pupil Legal Surname Pupil Legal Forename DOB M/F 2 year old funding? (please tick) Postcode Res Code Total Fund Wks Claimed Hrs/ Week Total Hrs Is grant being claimed elsewhere? (please give provider name and hours) Total number of hours claimed: NB: Grant can only be claimed for up to 15 hours per week per child – This includes attendance at Maintained Nursery classes within some Primary Schools. (Please refer to the Local Provider Agreement for further details.) Information given on this form will be used to cross check data with authorities bordering Wiltshire. Appendix 3 CERTIFICATION I certify that:
