Address means a postal address or, for the purposes of electronic communication, a fax number, an e-mail or postal address or a telephone number for receiving text messages in each case registered with the charity;
Fax Number Email Address: Credentialing Contact: Telephone Number: Fax Number: Email Address: Address Information Federal Tax ID Number: National Provider Identification: Attach a completed W9 form for each Federal Tax ID number. Physical Address – physical location of the Facility THIS ADDRESS AND PHONE NUMBER WILL APPEAR ON THE WEBSITE PROVIDER DIRECTORY. Physical Address: Mailing Address Mailing Address: City State ZIP Phone: Fax: Contact Person: Email Address: Mailing contact information, if listed, will be utilized for all legal, contractual notices as defined in section 11.2 or 12.2 of the facility contracts. An email address must be included for this contact in order to access the online fee schedules. All notices will be sent electronically. Billing/Remit Address – for claims payments and remittance statements ALL BILLING INFORMATION BELOW MUST MATCH THE INFORMATION REFLECTED ON THE CLAIMS SUBMITTED. Name Submitted on Claims: Billing Office Name (if applicable): Billing Address: City State ZIP Phone: Fax: Contact Person: Email Address: Additional Location Federal Tax ID Number: National Provider Identification: Attach a completed W9 form for each Federal Tax ID number. Physical Address – physical location of the Facility THIS ADDRESS AND PHONE NUMBER WILL APPEAR ON THE WEBSITE PROVIDER DIRECTORY. Physical Address: Mailing Address- for correspondence/credentialing Mailing Address: City State ZIP Phone: Fax: Contact Person: Email Address: Billing/Remit Address – for claims payments and remittance statements ALL BILLING INFORMATION BELOW MUST MATCH THE INFORMATION REFLECTED ON THE CLAIMS SUBMITTED. Name Submitted on Claims: Billing Office Name (if applicable): Billing Address: City State ZIP Phone: Fax: Contact Person: Email Address: Please use copies of these pages to report any additional locations. Network Provider Home Health Care Agency Contract Signature Page The Office of Management and Enterprise Services Employees Group Insurance Division (EGID), and the facility incorporated by reference the terms and conditions of the Network Facility Contract into this signature page and acknowledge EGID and the Facility further agree that the effective date of the Contract is the effective date denoted on the copy of the executed signature page returned to the Facility. The original of the signed document will remain on file in the office of EGID. FOR THE FACILITY: FOR EGID: Legal Name of Owner (Typed or Printed) Xxxx X. Xxxx Deputy Administrator Employees Group Insurance Division Trade Name/DBA (Typed or Printed) Federal Tax ID Number Address of the Facility: Authorized Officer or Representative (Typed or Printed) Title Signature Signature Date Please return the completed Application, Signature Page, and required attachments to: Office of Management Enterprise Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 Oklahoma City, OK 73112 Phone: 000-000-0000 or 000-000-0000 Fax: 000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx
Address for Notice Address for Notice: Attention: Supplier Contact Attention: Contract Administrator
Delivery Address means the address stated on the Order.
Phone Number Email Address: (Please Print) ______________________________________ ______________________________________ Dated: _______________ __, ______ Holder’s Signature: Holder’s Address:
Notice Address means with respect to the following entities:
Telephone Number Email Address:
Location Routing Number (LRN means the ten (10) digit number that is assigned to the network switching elements (Central Office–Host and Remotes as required) for the routing of calls in the network. The first six (6) digits of the LRN will be one of the assigned NPA NXX of the switching element. The purpose and functionality of the last four (4) digits of the LRN have not yet been defined but are passed across the network to the terminating switch.
FX Telephone Numbers means those telephone numbers with rating and routing point that are different from those of the geographic area in which the End User is physically located. FX Telephone Numbers that deliver second dial tone and the ability for the calling Party to enter access codes and an additional recipient telephone number remain classified as Feature Group A (FGA) calls, and are subject to the originating and terminating carrier’s tariffed Switched Exchange Access rates (also known as “Meet Point Billed” compensation).