IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM PROVIDER ENROLLMENT AGREEMENTProvider Enrollment Agreement • April 24th, 2022
Developmental Disabilities Independent Provider Enrollment Application and AgreementProvider Enrollment Agreement • October 20th, 2016
This Provider Enrollment Application and Agreement (the Agreement) sets forth the conditions and agreements for being enrolled as a Medicaid Independent Provider (non-PSW; hereinafter referred to as Provider) with the Department of Human Services (DHS). Under the terms of this Agreement, the Provider will receive a Provider number, as required in order to receive an authorization for services, submit payment claims, and to receive payment for Community Service Payments. Community Service Program services are provided to persons with intellectual or developmental disabilities (hereinafter referred to as Recipients). Payments for services are made using federal Medicaid or State of Oregon funds or a combination of both state and federal funds.
Provider Enrollment Agreement and Signature PageProvider Enrollment Agreement • March 4th, 2022
THE PROVIDER CERTIFIES THAT THE INFORMATION PROVIDED ON THIS ENROLLMENT FORM IS, TO THE BEST OF THE PROVIDER’S KNOWLEDGE, TRUE, ACCURATE AND COMPLETE AND THAT THE PROVIDER HAS READ THIS ENTIRE FORM BEFORE SIGNING. IN CONSIDERATION OF MEDICAID PAYMENTS MADE FOR APPROPRIATE MEDICALLY NECESSARY SERVICES RENDERED TO ELIGIBLE CLAIMANTS, AND IN ACCORDANCE WITH ANY RESTRICTIONS NOTED HEREIN, THE PROVIDER AGREES TO THE FOLLOWING:
Provider Enrollment AgreementProvider Enrollment Agreement • January 5th, 2017
(hereinafter the “Provider”) wishes to participate in the Connecticut Medical Assistance Program. For purposes of this Provider Enrollment Agreement (hereinafter the “Agreement”), the term “Connecticut Medical Assistance Program” means any and all of the health benefit programs administered by the State of Connecticut Department of Social Services (hereinafter “DSS”). The Provider represents and agrees as follows:
Provider Enrollment AgreementProvider Enrollment Agreement • June 25th, 2020
The Oregon Health Authority (OHA) administers Oregon’s medical assistance program for individuals eligible for Medicaid, the Children’s Health Insurance Program (CHIP), and other federally funded medical programs, called the Oregon Health Plan (OHP). To comply with Federal law 42 CFR 455 Subpart E, OHA is required to enroll eligible providers into the Oregon Medicaid Program, pursuant to Oregon Administrative Rule 943-120 and 410-120, as a condition of delivering health services to OHP members.
This agreement must be completed, signed, and returned to the IHCP for processing.Provider Enrollment Agreement • May 5th, 2020
By execution of this Agreement, the undersigned entity (“Provider”) requests enrollment as a provider in the Indiana Health Coverage Programs (“IHCP”). As an enrolled provider in the IHCP, the undersigned entity agrees to provide covered services and/or supplies to Indiana Health Coverage Program members
• EDI Provider Agreement and Enrollment FormProvider Enrollment Agreement • August 9th, 2016
• Once you have received notification that you have been linked, you MUST contact Office Ally at (360) 975-7000 Option 1 to notify us of the approval BEFORE submitting claims electronically.
Centers for Medicare & Medicaid Services, HHS § 424.68Provider Enrollment Agreement • July 17th, 2023
Provider Enrollment AgreementProvider Enrollment Agreement • July 7th, 2015
(hereinafter the “Provider”) wishes to participate in the Connecticut Medical Assistance Program. For purposes of this Provider Enrollment Agreement (hereinafter the “Agreement”), the term “Connecticut Medical Assistance Program” means any and all of the health benefit programs administered by the State of Connecticut Department of Social Services (hereinafter “DSS”). The Provider represents and agrees as follows:
OHIO DEPARTMENT OF MEDICAIDProvider Enrollment Agreement • January 18th, 2022
This provider agreement is a contract between the Ohio Department of Medicaid (the Department) and the undersigned provider of medical assistance services in which the Provider agrees to comply with the terms of this provider agreement, Ohio statutes, Ohio Administrative Code rules, and Federal statutes and rules, and agrees and certifies to:
PROVIDER ENROLLMENT AGREEMENTProvider Enrollment Agreement • September 1st, 2009
CMAP Express is a non-profit Central Fill Pharmacy which has acquired contracts with several drug manufacturers to provide us with bulk donation medications. These contracts allow CMAP Express to offer free medications to your patients who meet certain guidelines.
PROVIDER ENROLLMENT AGREEMENT TERMS OF AGREEMENTProvider Enrollment Agreement • August 28th, 2018 • Michigan
This Agreement is between _________________, hereinafter referred to as “Provider,” and Region B3 Area Agency on Aging DBA CareWell Services SW, 200 W. Michigan Ave, Suite 102, Battle Creek, MI 49017, herein referred to as “Waiver Agent.”
INTRODUCTIONProvider Enrollment Agreement • February 19th, 2020
The ABC Quality Rating & Improvement System (ABC Quality) is a federally funded program administered by the SC Department of Social Services. The standards and indicators used by ABC Quality are based on research and practice focused on the health and safety of children, staff education and qualifications, supportive staff-child interactions, and meaningful learning activities.
Provider Enrollment AgreementProvider Enrollment Agreement • June 24th, 2015
In order to participate in the Delaware Screening for Life Program (SFL), I, on behalf of this medical office, group practice, Health Maintenance Organization, health department, community/migrant/rural clinic, or other entity, agree to the following:
Delaware Division of Public Health’s Screening for Life ProgramProvider Enrollment Agreement • January 30th, 2024
practice, Health Maintenance Organization, health department, community/migrant/rural clinic, or other entity, agree to
PROVIDER ENROLLMENT AGREEMENTProvider Enrollment Agreement • March 14th, 2016
This Agreement sets forth the conditions for being enrolled with the Department of Human Services (DHS) to provide Consultant services (hereinafter referred to as “Provider”) and to receive a provider number in order to submit payment claims, and to receive payment for services to developmentally disabled clients of Community Developmental Disability Programs or Brokerages. Payments for services are made using federal Medicaid funds, or State of Oregon funds, or a combination of both state and federal funds.
To West Virginia Provider Enrollment Agreement with Department ofProvider Enrollment Agreement • September 22nd, 2014
This Addendum is attached and incorporated into the West Virginia Medicaid Provider Enrollment Agreement between the Department of Health and Human Resources, Bureau for Medical
PROVIDER ENROLLMENT AGREEMENTProvider Enrollment Agreement • February 5th, 2018
This 340 B Program Addendum (“Addendum”) is made between the State of Vermont, Department of Vermont Health Access (“DVHA”) and (“340B Partner”) and incorporated into the Provider Enrollment Agreement between them dated (“Provider Agreement”). This Addendum shall replace and supersede in their entirety all prior 340B Program amendments, addenda or other 340B Program-specific attachments or modifications to the Provider Agreement.
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM PROVIDER ENROLLMENT AGREEMENTProvider Enrollment Agreement • August 5th, 2019
Provider Enrollment AgreementProvider Enrollment Agreement • December 28th, 2016
This Enrollment Agreement sets forth the conditions for being enrolled as a Provider with the Oregon Health Authority (“Authority”) and to receive a Provider Number in order to submit claims, and receive payment, for medical care, services, equipment and/or supplies furnished by Provider to persons eligible for medical assistance in Oregon ("Recipients"). Payments for medical assistance are made using Medicaid, State Children's Health Insurance Program, or funds from other federally funded programs.
LEVEL C PROVIDER ENROLLMENT FORM AND AGREEMENTProvider Enrollment Agreement • February 3rd, 2015
n New n Update FEIN: ( ) OR Social Security No.: ( ) Provider/Agency Name: Facility Name: (If different from Provider Name) County in which Facility is Located: Facility Telephone: ( ) Director’s Name: Alternate Contact Person/Name: Telephone: ( ) Owner’s Name: Telephone: ( ) Facility Address:
Developmental Disabilities Agency Medicaid Provider Enrollment Application and Agreement Revised 10/13/2016Provider Enrollment Agreement • October 20th, 2016
This Provider Enrollment Application and Agreement, hereinafter referred to as the “Agreement”, sets forth the conditions and agreements for being enrolled as a Provider with the State of Oregon Department of Human Services (DHS), Office of Developmental Disabilities Services (ODDS) and to receive a Provider number. The Provider number is required prior to receiving authorization to provide services, to submit claims for payment, and to receive payment for Medicaid services furnished by Provider to Medicaid-eligible individuals in Oregon home and community-based settings. Payments for services are made using federal Medicaid and state funds.
BabyNet Provider Enrollment RequirementsProvider Enrollment Agreement • March 19th, 2021
We are requesting that all providers (to include rendering service providers) submit the following documents to the South Carolina Department of Health and Human Services (SCDHHS) BabyNet State Office to establish your BabyNet Agreement.
PROVIDER CHECK LISTProvider Enrollment Agreement • January 26th, 2018
IDAHO IMMUNIZATION PROGRAM PROVIDER ENROLLMENT AGREEMENTProvider Enrollment Agreement • October 31st, 2012
To receive vaccines through the Idaho Immunization Program, which includes the federal Vaccines for Children (VFC) program, and to receive federal and state procured vaccine at no cost, I, on behalf of myself and all practitioners for whom I am the medical/agency director or equivalent, agree to the following:
Arizona Vaccines for Adults (VFA) Program Provider Enrollment Agreement October 2015 – September 2018Provider Enrollment Agreement • August 18th, 2015
Facility Name: VFA Pin#: Facility Address: City: County: State: Zip: Telephone: Fax: Shipping Address (if different than facility address): City: County: State: Zip: MEDICAL DIRECTOR OR EQUIVALENT Instructions: The official VFA registered health care provider signing the agreement must be a practitioner authorized to administer adult vaccines under state law who will also be held accountable for compliance by the entire organization and its VFA providers with the responsible conditions outlined in the provider enrollment agreement. The individual listed here must sign the provider agreement. Last Name, First, MI: Title: Specialty: License No.: Medicaid or NPI No.: Employer Identification No.(optional): Provide Information for second individual as needed: Last Name, First, MI: Title: Specialty: License No.: Medicaid or NPI No.: Employer Identification No.:(optional): Primary Vaccine Coordinator Name: Telephone: Email: Completed annual training: Type of training received: Yes No
WV MEDICAID DIRECT CARE PROVIDER ENROLLMENT AGREEMENT and SIGNATURE www.wvmmis.comProvider Enrollment Agreement • August 15th, 2022
A SEPARATE PROVIDER AGREEMENT MUST BE COMPLETED BY EACH DIRECT CARE PROVIDER AND A REPRESENTATIVE OR AUTHORIZED DELEGATE FOR THE GROUP/FACILITY.
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM PROVIDER ENROLLMENT AGREEMENTProvider Enrollment Agreement • September 19th, 2014
PROVIDER CHECK LISTProvider Enrollment Agreement • December 6th, 2019
ContractProvider Enrollment Agreement • October 21st, 2021
PROVIDER ENROLLMENT AGREEMENT 340B AMENDMENTProvider Enrollment Agreement • March 26th, 2015
This amendment complies with the requirements of 42 C.F.R. 438.6 that require a Medicaid MCO (Managed Care Organization) to have contracts with its provider network.
Topic: Provider Enrollment Agreements and the clinical team’s crucial role Hello Clinical Team,Provider Enrollment Agreement • April 19th, 2023
There is a lot of responsibility associated with administering any vaccine but especially the COVID-19 vaccine. As a mobile vaccine site and an extension of UL Lafayette, it is important that you are aware of the compliance requirements. In your role, you will be assisting with making sure these agreements are upheld.
OHIO DEPARTMENT OF MEDICAIDProvider Enrollment Agreement • April 8th, 2022
This provider agreement is a contract between the Ohio Department of Medicaid (the Department) and the undersigned provider of medical assistance services in which the Provider agrees to comply with the terms of this provider agreement, Ohio statutes, Ohio Administrative Code rules, and Federal statutes and rules, and agrees and certifies to:
Provider Enrollment AgreementProvider Enrollment Agreement • June 24th, 2015
In order to participate in the Delaware Screening for Life Program (SFL), I, on behalf of this medical office, group practice, Health Maintenance Organization, health department, community/migrant/rural clinic, or other entity, agree to the following:
PROVIDER ENROLLMENT AGREEMENTProvider Enrollment Agreement • October 21st, 2020 • Michigan
THIS AGREEMENT is entered into between and hereinafter referred to as “Provider,” and Region IV Area Agency on Aging, Inc., 2900 Lakeview Avenue, St. Joseph, Michigan 49085, herein referred to as “Area Agency on Aging” or “AAA.”
