Get the free N.C. DHHS: DHHS 4041 Vaccine Administration Record - immunize nc
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1.? Last Name First Name ?????? MI 2.? Patient Number ????? ?? H 3.? Date of Birth Month Day Year o?1.? White???o?2.? Black ?? Ethnicity: ? Hispanic Origin? O?3.? Am. Indian/Alaskan Native ?? ?1.?
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What is nc dhhs dhhs 4041?
nc dhhs dhhs 4041 is a form used by the North Carolina Department of Health and Human Services to collect information on Medicaid provider enrollment.
Who is required to file nc dhhs dhhs 4041?
All Medicaid providers in North Carolina are required to file nc dhhs dhhs 4041.
How to fill out nc dhhs dhhs 4041?
To fill out nc dhhs dhhs 4041, providers need to provide information about their practice, services offered, and billing details as requested on the form.
What is the purpose of nc dhhs dhhs 4041?
The purpose of nc dhhs dhhs 4041 is to ensure that Medicaid providers in North Carolina meet all enrollment requirements and are eligible to provide services to Medicaid beneficiaries.
What information must be reported on nc dhhs dhhs 4041?
Providers must report information such as their practice name, contact information, Medicaid ID number, services offered, and any relevant certifications or accreditations.
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