Common Contracts
1 similar Single Case Agreement (Sca) contracts
Physical and Behavioral Health Single Case Agreement (SCA) ApplicationSingle Case Agreement (Sca) • August 22nd, 2023
Date of Request: Funding Requested: Medicaid IPRS/State Medicaid Enrolled Provider: Yes No Provider Type Agency ResidentialProvider Solo LIP Group Practice Physical Health Provider Provider Name (as listed in NC Tracks): DBA Name (if applicable): Federal Tax ID: Corporate Address: Agency Mailing Address (if different from corporate address): Agency Billing Address:
