Common Contracts
1 similar Provider Payment Agreement contracts
Provider Payment AgreementProvider Payment Agreement • August 7th, 2018
Provider Legal Business Name: Date of Request: DBA Name (if applicable): Provider Type Agency Hospital Licensed IndependentPractitioner Group Practice CABHA Facility Only Classification Not for Profit C-Corp S-Corp Sole Proprietorship Limited Liability Partnership Cooperative Government General Partnership Limited Liability Corp (LLC) 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 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:
