Common Contracts
2 similar Facility/Ancillary Provider Agreement contracts
APPENDIX 1 (Facility/Ancillary Provider Agreement)Facility/Ancillary Provider Agreement • December 2nd, 2020
Legal name: (As registered with the Secretary of State) DBA/Directory listing name: (If applicable) Office contact name and title: Email address: Contract Signature of Authority:(who will sign the contract?) Email address: Phone: Fax: Website address: Please mark all that apply to practice: Practice is female-owned(Optional) Practice is minority-owned(Optional) Practice is telehealth only Practice provides a HIPAA compliant, private/secure location to render telehealth services Practice provides American Sign Language (ASL) servicesFederally Qualified Health Center (FQHC) Rural Health Center (RHC)Community Mental Health Center (CMHC) Pediatric onlyWomen only Adults onlyCapable of billing Medicare Capable of billing Medicaid
APPENDIX 1 (Facility/Ancillary Provider Agreement)Facility/Ancillary Provider Agreement • September 2nd, 2020
Legal name: (As registered with the Secretary of State) DBA/Directory listing name: (If applicable) Office contact name and title: Email address: Contract Signature of Authority:(who will sign the contract?) Email address: Phone: Fax: Website address: Please mark all that apply to practice: Practice is female-owned(Optional) Practice is minority-owned(Optional) Practice is telehealth only Practice provides a HIPAA compliant, private/secure location to render telehealth services Practice provides American Sign Language (ASL) servicesFederally Qualified Health Center (FQHC) Rural Health Center (RHC)Community Mental Health Center (CMHC) Pediatric onlyWomen only Adults onlyCapable of billing Medicare Capable of billing Medicaid
