DIVISION OF MEDICAL SERVICES MEDICAL ASSISTANCE PROGRAM PROVIDER APPLICATION
➤ Gửi thông báo lỗi ⚠️ Báo cáo tài liệu vi phạmNội dung chi tiết: DIVISION OF MEDICAL SERVICES MEDICAL ASSISTANCE PROGRAM PROVIDER APPLICATION
DIVISION OF MEDICAL SERVICES MEDICAL ASSISTANCE PROGRAM PROVIDER APPLICATION
DIVISION OF MEDICAL SERVICESMEDICAL ASSISTANCE PROGRAMPROVIDER APPLICATIONAs a condition tor entering into or renewing a provider agreement, all appli DIVISION OF MEDICAL SERVICES MEDICAL ASSISTANCE PROGRAM PROVIDER APPLICATIONicants must complete this provider application. A true, accurate and complete disclosure of all requested information is required by the Federal and State Regulations that govern the Medical Assistance Program. Failure of an applicant to submit the requested information or the submission of inaccura DIVISION OF MEDICAL SERVICES MEDICAL ASSISTANCE PROGRAM PROVIDER APPLICATIONte or incomplete information may result in refusal by the Medical Assistance program to enter Into, renew or continue a provider agreement with the apDIVISION OF MEDICAL SERVICES MEDICAL ASSISTANCE PROGRAM PROVIDER APPLICATION
plicant. Furthermore, the applicant is required by Federal and State Regulations to update the information submitted on the Provider Application.WheneDIVISION OF MEDICAL SERVICESMEDICAL ASSISTANCE PROGRAMPROVIDER APPLICATIONAs a condition tor entering into or renewing a provider agreement, all appli DIVISION OF MEDICAL SERVICES MEDICAL ASSISTANCE PROGRAM PROVIDER APPLICATIONe Rock, AR 72203-8105All dates, except where otherwise specified, should be written in the month/day/year (MMDDYY) format. Please print all information.All ProvidersFacilities OnlyPharmacists/Registered Respiratory Therapist OnlyProvider Group AffiliationsAll Providers (optional)Primary Care Physici DIVISION OF MEDICAL SERVICES MEDICAL ASSISTANCE PROGRAM PROVIDER APPLICATIONanAll ProvidersAll ProvidersThis information is divided into sections. The following describes which sections are to be completed by the applicant:SecDIVISION OF MEDICAL SERVICES MEDICAL ASSISTANCE PROGRAM PROVIDER APPLICATION
tion ISection IISection IIISection IVElectronic Fund TransferManaged Care AgreementW-9 Tax FormContractOwnership and ConvictionDisclosureDisclosure ofDIVISION OF MEDICAL SERVICESMEDICAL ASSISTANCE PROGRAMPROVIDER APPLICATIONAs a condition tor entering into or renewing a provider agreement, all appliDIVISION OF MEDICAL SERVICESMEDICAL ASSISTANCE PROGRAMPROVIDER APPLICATIONAs a condition tor entering into or renewing a provider agreement, all appliGọi ngay
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