Common Contracts
22 similar Enrollment Agreement contracts
ENROLLMENT AGREEMENTEnrollment Agreement • February 9th, 2024
Emergency Phone Number 911 Area Agency on Aging (AAA) County Office of Aging (215) 765-9040 County Ombudsman (215) 545-5724 Protective Services (800) 490-8505 or 911 Department of Human Services County Assistance Office (215) 560-5400 Independent Enrollment Broker (877) 550-4227 Office of Long-Term Living Participant Hotline (800) 757-5042 LIFE Provider Health Clinic (267) 787-8243 Main Phone Number (267) 787-8300 On Call Nurse (after 5 p.m.) (267) 787-8243
ENROLLMENT AGREEMENTEnrollment Agreement • January 17th, 2024
Emergency Phone Number 911 Area Agency on Aging (AAA) County Office of Aging (215) 765-9040 County Ombudsman (215) 545-5724 Protective Services (800) 490-8505 or 911 Department of Human Services County Assistance Office (215) 560-5400 Independent Enrollment Broker (877) 550-4227 Office of Long-Term Living Participant Hotline (800) 757-5042 LIFE Provider Health Clinic (267) 787-8243 Main Phone Number (267) 787-8300 On Call Nurse (after 5 p.m.) (267) 787-8243
ENROLLMENT AGREEMENTEnrollment Agreement • January 19th, 2023
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
Enrollment Agreement Changes for 2023Enrollment Agreement • December 7th, 2022
Kinder Park ENROLLMENT AGREEMENTEnrollment Agreement • December 7th, 2022
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
Valley View ENROLLMENT AGREEMENTEnrollment Agreement • December 7th, 2022
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
IMPORTANT INFORMATION SHEETEnrollment Agreement • December 7th, 2022
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
ENROLLMENT AGREEMENTEnrollment Agreement • December 7th, 2022
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
ENROLLMENT AGREEMENTEnrollment Agreement • April 13th, 2022
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
ENROLLMENT AGREEMENTEnrollment Agreement • April 13th, 2022
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
ENROLLMENT AGREEMENTEnrollment Agreement • April 13th, 2022
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
ENROLLMENT AGREEMENTEnrollment Agreement • April 13th, 2022
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
ENROLLMENT AGREEMENTEnrollment Agreement • April 13th, 2022
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
ENROLLMENT AGREEMENTEnrollment Agreement • March 4th, 2022
Emergency Phone Number 911 Area Agency on Aging (AAA) County Office of Aging (215) 765-9040 County Ombudsman (215) 545-5724 Protective Services (800) 490-8505 or 911 Department of Human Services County Assistance Office (215) 560-5400 Independent Enrollment Broker (877) 550-4227 Office of Long-Term Living Participant (800) 757-5042 Hotline
ENROLLMENT AGREEMENTEnrollment Agreement • February 21st, 2022
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
ENROLLMENT AGREEMENTEnrollment Agreement • December 15th, 2021
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
ENROLLMENT AGREEMENTEnrollment Agreement • December 15th, 2021
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
ENROLLMENT AGREEMENTEnrollment Agreement • December 15th, 2021
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
ENROLLMENT AGREEMENTEnrollment Agreement • December 13th, 2021
_Poison Control Center (800) 222-1212 _Office of Civil Rights (215) 656-8541 _Pennsylvania Human Relations Comm (215) 560-2496 PA Relay Service for Hearing Impaired (800) 654-5984
ENROLLMENT AGREEMENTEnrollment Agreement • March 24th, 2021
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
Enrollment AgreementEnrollment Agreement • August 8th, 2018
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
Enrollment AgreementEnrollment Agreement • August 8th, 2018
LIFE Inpatient Facilities Form Appendix C LIFE Monthly Premium and Payment Agreement Form Appendix D LIFE Medical Record Review and Copying Cost Agreement Form Appendix E Non-Discrimination Notice Appendix F
