Common Contracts
1 similar Provider Enrollment Application and Agreement contracts
In Home Care Agency, Specialized Living Program, Adult Day ServicesMedicaid Provider Enrollment Application and Agreement Revised 05/22/2018 This Provider Enrollment Application and Agreement, hereinafter referred to as the “Agreement”, sets forth the...Provider Enrollment Application and Agreement • November 16th, 2022
County: Phone number: Fax number: Mailing address: City/State/ZIP(+4): Email: Tax ID number (SSN or FEIN): DOB (if applicable): In-Home Agency License number, if applicable: License effective date: License expiration date: Contact name: Contact phone: Contact email:
