Common Contracts
1 similar Provider Payment Agreement contracts
Provider Payment AgreementProvider Payment Agreement • February 24th, 2023
Provider Legal Business Name: Date of Request: DBA Name (if applicable): Provider Type ☐ Agency ☐ Hospital ☐ Licensed Facility ☐ Other Other Description: Tax Classification Site Address Where Services Took Place (Street, City, State, Zip+4): Mailing Address (if different): Main Contact Name and Position: Phone Number: Email Address: Additional information required for Attending Provider/Practitioner License #: Date of Birth: Name as it appears on License: Member Information Member Name: Member’s Date of Birth: Member’s Medicaid Number: Is this PPA being requested due to a Medicaid transition to Sandhills Center? ☐YES ☐NO Date(s) of Service: (start date and end date; see #6 below) Service Code(s) with Service Description:
