Provider Election Form and AgreementProvider Election Form and Agreement • March 23rd, 2021
IMPORTANT:1. Type or print legibly.2. Return this completed form to: DHCS Hospital PE ProgramAttn: Xerox State Health Care, LLCP.O. Box 15508 Sacramento, CA 95852-15083. If you have any questions regarding this Hospital PE Program Provider Election Form and Agreement, please call 1-800-541-5555. Official Use Only Reviewer Name: ___________________________ Date Received:______________________ Date Review Completed:______________________ Part 1. Hospital Contact Information and Participation Identification Information Legal Name of Provider Business Name of Provider if different from legal name Service Address (number & street) City State ZIP Code Contact Phone number Contact Fax number Contact Email address Contact Person and Title Federal Employer ID Number or Taxpayer Identification Number Hospital License Number National Provider Identifier Part 2. Pay-to Information Pay-to Name of Business or Person to which payment should be issued Pay-to Address City State ZIP Code Pay-to Phone n
