Common Contracts
1 similar Provider Payment Agreement contracts
Provider Payment AgreementProvider Payment Agreement • August 28th, 2018
Provider Legal Business Name: Date of Request: DBA Name (if applicable): Provider Type Agency Hospital Licensed IndependentPractitioner Group Practice Facility Only Tax Classification Individual/sole proprietor orsingle member LLC C-Corporation S-Corporation Partnership Trust/estate Limited liability company Enter the tax classification (C= C Corporation, S= S Corporation, P= Partnership) Other Physical Address (Street, City, State, Zip+4) Mailing Address (if different): Phone Number: Email Address: Federal Tax ID #: Medicaid Number: NPI Number: Taxonomy Number: Additional information required for Licensed Independent Practitioner (LIP): Social Security #: Date of Birth: Name as it appears on Degree: Highest Degree Date Earned: Academic Institution: Consumer Information Consumer Name: Consumer’s Date of Birth: Consumer’s Medicaid Number: Date(s) of Service: (start date and end date; see #6 below) Service Code(s) with Service Description:
