Provider Type. To be eligible to deliver the VPK Program, PROVIDER must be either a public school or a private provider (a licensed child care facility, a licensed family day care home, a licensed large family child care, a non-public school exempt from licensure, or a faith-based child care provider exempt from licensure). A charter school that includes VPK in its charter is a public school and shall only execute this Contract with the approval and oversight of the school district. A charter school that does not include VPK in its charter must meet the requirements to be a private provider to be eligible to deliver the VPK Program. Check the box to indicate PROVIDER’s type: ☐A public school (Form OEL-VPK 20PS must be completed as an authorized attachment to this Contract.) ☐A private provider (Form OEL-VPK 20PP must be completed as an authorized attachment to this Contract.)
Provider Type. To be eligible to deliver the VPK Program, PROVIDER must be either a public school or a private provider (a licensed child care facility, a licensed family day care home, a licensed large family child care, a non-public school exempt from licensure, faith-based child care provider exempt from licensure, or a child development program that is accredited by a national accrediting body and operates on a military installation that is certified by the United States Department of Defense). A charter school that includes VPK in its charter is a public school and shall only execute this Contract with the approval and oversight of the school district. A charter school that does not include VPK in its charter must meet the requirements to be a private provider to be eligible to deliver the VPK Program. Check the box to indicate PROVIDER’s type: ☐A public school (Form DEL-VPK 20PS must be completed as an authorized attachment to this Contract.) ☐A private provider/non-public school (Form DEL-VPK 20PP must be completed as an authorized attachment to this Contract.)
Provider Type. Required - Identifies the physician’s general area of service with an alpha character. See the provider description reference table for all accepted values. Treating providers that are members of a group will have their own record, provider type P, PCP indicator P, so the group or the individual may be selected for enrollment. For PSN and Medipass-MPN and ER Diversion, each Beneficiary will be enrolled to the Supergroup, the individual Provider selected by the beneficiary will be provided to the PSN/MPN/PERD in the monthly Recipient Data file.
Provider Type. The rate paid herein shall be adjusted for Provider and/or Covered Service type delivered. The amount of compensation is based on the treating Provider’s licensure and Health Plan’s credentialing requirements for that discipline, not on the Provider’s academic credentials.
Provider Type. This attachment is designed for use by public school districts and/or public schools. If a VPK site under this Contract is a charter school, the COALITION shall confirm that VPK is in its charter before use of this attachment.
Provider Type. To be eligible to deliver the VPK Program, PROVIDER must be either a public school or a private provider (a licensed child care facility, a licensed family day care home, a licensed large family child care, a non-public school exempt from licensure, or a faith-based child care provider exempt from licensure).
Provider Type. To be eligible to deliver the school readiness program, PROVIDER must be one of the provider types identified in s. 1002.88(1)(a), F.S. This form is designed for use by licensed providers. PROVIDER must check the box to indicate PROVIDER’s type: A child care facility licensed under s. 402.305, F.S. A family day care home licensed or registered under s. 402.313, F.S. A large family child care home licensed under s. 402.3131, F.S. A before-school or after-school program described in s. 402.305(1)(c), F.S., which has elected to be licensed.
Provider Type. Enter the three (3) digit number to indicate other types of participation from Attachment A.
Provider Type. Enter the appropriate PROVIDER TYPE that corresponds with the Provider Type Code entered in 10a. Type Code (field 10a) Program Type of Provider (field 10b) 48 Medicaid Adult Substance Abuse 30 Medicaid Adult Day Care - Bath Services, Registered Nurse MS-84 9 Medicaid Ambulatory Surgical Center (ASC) Copy of License; MS-84 15 Medicaid Anesthesiologist Copy of License; MS-84 41 Medicaid Assertive Community Treatment (ACT MRO Program MS-84 68 Medicaid Audiologist Copy of License; MS-84; 83 Medicaid Autism Waiver - Applied Behavioral Analysis Technician MS-84 Medicaid Autism Waiver - EIBI Autism Waiver FA-84 83 Medicaid Autism Waiver - Lead Therapist MS-84 83 Medicaid Autism Waiver - Supervising Behavioral Therapist MS-84 5 Medicaid Chiropractor Copy of License; MS-84 12 Medicaid Clinic - Hospital Based, Licensed Mental Centers MS-84; 13 Medicaid Clinic - Professional (PC) MS-84 44 Medicaid Community Support (CSW) MRO Program MS-84; 45 Medicaid Day Rehabilitation (DAYR) MRO Program MS-84; 77 Medicaid Day Treatment Provider (DAY) MS-84; 40 Medicaid Dentist (DDS) Copy of License; MS-84 21 Medicaid Dispensing Physician (MD) Copy of License; XX-00 00 Xxxxxxxx Xxxxxxxxx Transportation MS-84 17 Medicaid Federally Qualified Health Center (FQHC) MS-84; CMS Documentation of Status; Out of State rate letter 60 Medicaid Hearing Instrument Specialist (HEAR) MS-84 14 Medicaid Home Health Agency (HHAG) MS-84 59 Medicaid Hospice (HSPC) MS-84 10 Medicaid Hospital Copy of License; CLIA certification; CMS-1539 25 Medicaid Indian Health Hospital Clinic (IHSH) SSA-1539; MS-84 16 Medicaid Laboratory (Independent) CMS-1539 42 Medicaid Licensed Dental Hygienist (LDH) Copy of License; MS-84 78 Medicaid Licensed Drug & Alcohol Counselor (LDAC) Copy of License; MS-84 39 Medicaid Licensed Independent Mental Health Practi- tioner (LIMHP) Copy of License; MS-84; 63 Medicaid Licensed Medical Nutrition Therapist (LMNT) Copy of License; MS-84; list of specific services providing 36 Medicaid Licensed Mental Health Practitioner (LMHP) Copy of License; MS-84; 31 Medicaid Licensed Practical Nurse (LPN) Copy of License; MS-84 67 Medicaid Licensed Psychologist (PHD) Copy of License; MS-84; 69 Medicaid Medicaid in Public Schools (MIPS) Occupational Therapist Copy of License; MS-84 32 Medicaid Medicaid in Public Schools (MIPS) Physical Therapist Copy of License; MS-84 68 Medicaid Medicaid in Public Schools (MIPS) Speech Pathologist Copy of License; MS-84 35 Medicaid Direct Care Staff MS-84; 34 Medic...
Provider Type. This attachment is designed for use by private providers. PROVIDER must check the box to indicate PROVIDER type: ☐ A child care facility licensed under s. 402.305, F.S. ☐ A family day care home licensed under s. 402.313, F.S. ☐ A large family child care home licensed under s. 402.3131, F.S. ☐ A nonpublic school exempt from licensure under s. 402.3025(2), F.S., that also either holds a current Gold Seal Quality Care designation under s. 402.281 F.S., or accredited by an accrediting association under s. 1002.55(3)(b)1., F.S. ☐ A faith-based child care provider exempt from licensure under s. 402.316, F.S., that also either holds a current Gold Seal Quality Care designation under s. 402.281 F.S., or accredited by an accrediting association under s. 1002.55(3)(b)1., F.S.
