Common use of Information for Providers Clause in Contracts

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. 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 - Ownership Disclosure Form, as required to comply with Laws, Program Requirements, and Government Contract ATTACHMENT B PROGRAM ATTACHMENTS (See following attachments) ATTACHMENT B-1 NORTH CAROLINA KENTUCKY MEDICAID AND CHIP PROGRAM ATTACHMENT