Provider Payment AgreementProvider Payment Agreement • February 24th, 2023
Provider Legal Business Name: Date of Request: DBA Name (if applicable): Provider Type ☐ Agency ☐ Hospital ☐ Licensed Facility ☐ Other Other Description: Tax Classification Site Address Where Services Took Place (Street, City, State, Zip+4): Mailing Address (if different): Main Contact Name and Position: Phone Number: Email Address: Additional information required for Attending Provider/Practitioner License #: Date of Birth: Name as it appears on License: Member Information Member Name: Member’s Date of Birth: Member’s Medicaid Number: Is this PPA being requested due to a Medicaid transition to Sandhills Center? ☐YES ☐NO Date(s) of Service: (start date and end date; see #6 below) Service Code(s) with Service Description:
PROVIDER PAYMENT AGREEMENTProvider Payment Agreement • July 26th, 2021
Your patient is a member of Zion Health, a non-profit medical cost sharing organization. This means Zion Health provides the administrative structure
ContractProvider Payment Agreement • August 22nd, 2023
Managing Mental Health, Intellectual/Developmental Disabilities and Substance Abuse Services 910-673-9111 (FAX) 910-673-6202 www.sandhillscenter.org
Provider Payment AgreementProvider Payment Agreement • February 3rd, 2022
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:
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:
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:
