Common use of TO BE COMPLETED BY PROVIDER Clause in Contracts

TO BE COMPLETED BY PROVIDER. I declare and affirm under the penalties of perjury that this Agreement has been examined by me, and to the best of my knowledge and belief, is in all things true and correct. I further declare and affirm under the penalties of perjury that any claim to be submitted pursuant to this Agreement will be examined by me, and to the best of my knowledge and belief, will be in all things true and correct. PROVIDER NAME: BY: Authorized Signature NAME/TITLE: APPLICATION ID: If application was submitted online FEDERAL TAX I.D. NUMBER: TAX I.D. NAME: DATE: TO BE COMPLETED BY MEDICAL SERVICES APPROVED BY: Xxxxxx Xxxxxxxx, Program Administrator DATE: PROVIDER NUMBER: ************************************************************************************************************************ MAIL SIGNED AGREEMENT AND OTHER APPLICABLE DOCUMENTATION TO: DEPARTMENT OF SOCIAL SERVICES FINANCE/EBT 000 XXXXXXXXX XXXXX XXXXXX, XX 00000-0000

TO BE COMPLETED BY PROVIDER. I declare and affirm under the penalties of perjury that this Agreement has been examined by me, and to the best of my knowledge and belief, is in all things true and correct. I further declare and affirm under the penalties of perjury that any claim to be submitted pursuant to this Agreement will be examined by me, and to the best of my knowledge and belief, will be in all things true and correct. PROVIDER NAME: APPLICATION ID: BY: Authorized Signature BILLING NPI: BILLING NPI: NAME/TITLE: APPLICATION ID: If application was submitted online FEDERAL TAX I.D. NUMBER: TAX I.D. NAMEBILLING NPI: DATE: SERVICING NPI: TO BE COMPLETED BY MEDICAL SERVICES APPROVED BY: Xxxxxx Xxxxxxxx, Program Administrator DATE: PROVIDER NUMBER: **********************DATE: ************************************************************************************************** MAIL APPLICATION COVER SHEET, SIGNED AGREEMENT AGREEMENT, AND OTHER APPLICABLE DOCUMENTATION TO: DEPARTMENT OF SOCIAL SERVICES FINANCE/EBT DIVISION OF MEDICAL SERVICES 000 XXXXXXXXX XXXXX XXXXXXPIERRE, XX 00000SD 57501-00002291 QUESTIONS: 1-800- 452-7691 (In State Providers)

TO BE COMPLETED BY PROVIDER. I declare and affirm under the penalties of perjury that this Agreement has been examined by me, and to the best of my knowledge and belief, is in all things true and correct. I further declare and affirm under the penalties of perjury that any claim to be submitted pursuant to this Agreement will be examined by me, and to the best of my knowledge and belief, will be in all things true and correct. PROVIDER NAME: APPLICATION ID: BY: Authorized Signature BILLING NPI: BILLING NPI: NAME/TITLE: APPLICATION ID: If application was submitted online FEDERAL TAX I.D. NUMBER: TAX I.D. NAMEBILLING NPI: DATE: SERVICING NPI: TO BE COMPLETED BY MEDICAL SERVICES APPROVED BY: Xxxxxx Xxxxxxxx, Program Administrator DATE: PROVIDER NUMBER: **********************DATE: ************************************************************************************************** MAIL APPLICATION COVER SHEET, SIGNED AGREEMENT AGREEMENT, AND OTHER APPLICABLE DOCUMENTATION TO: DEPARTMENT OF SOCIAL SERVICES FINANCE/EBT DIVISION OF MEDICAL SERVICES 000 XXXXXXXXX XXXXX XXXXXX, XX 00000-00000000 QUESTIONS: 1-800- 452-7691 (In State Providers)