Common Contracts
1 similar Electronic Signature Agreement contracts
Electronic Signature AgreementElectronic Signature Agreement • January 30th, 2017
The undersigned Individual and Employing Entity attest that they have entered into an agreement effective on the date indicated below. Both parties agree an authorized representative of the Employing Entity has the authority to sign and submit the electronic Illinois Department of Healthcare and Family Services Medical Assistance Provider Enrollment Trading Partner Agreement and to maintain enrollment information through the H FS IMPACT Provider Enrollment Subsystem. Email completed form to Impact.Help@Illinois.Gov
