Common use of PROVIDER OR SUPPLIER INFORMATION Clause in Contracts

PROVIDER OR SUPPLIER INFORMATION. Line 1: Enter the provider’s/supplier’s legal business name or the name of the physician or individual practitioner, as reported to the Internal Revenue Service (IRS). The account to which EFT payments are made must exclusively bear the name of the physician or individual practitioner, or the legal business name of the person or entity enrolled with Medicare. Line 2: Enter the chain organization’s name or the home office legal business name if different from the chain organization name. Line 3: Enter the account holder’s street address. Line 4: Enter the account holder’s city, state, and zip code. Line 5: Enter the tax identification number as reported to the IRS. If the business is a corporation, provide the Federal employer identification number, otherwise provide your Social Security Number.

PROVIDER OR SUPPLIER INFORMATION. Line 1: Enter the provider’s/supplier’s legal business name or the name of the physician or individual practitioner, as reported to the Internal Revenue Service (IRS). The account to which EFT payments are made must exclusively bear the name of the physician or individual practitioner, or the legal business name of the person or entity enrolled with Medicare. Line 2: Enter the chain organization’s name or the home office legal business name if different from the chain organization name. Line 3: Enter the account holder’s street address. Line 4: Enter the account holder’s city, state, and zip code. Line 5: Enter the tax identification number as reported to the IRS. If the business is a corporation, provide the Federal employer identification number, otherwise provide your Social Security Number.