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State of California Department of Health Care ServicesAGREEMENT FOR USE OF DATA CONTAINING INDIVIDUAL AND PROVIDER SPECIFIC INFORMATIONNOTE: Requestors must initial every page, date and sign this
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Individual and provider specific refers to the information that is unique to each individual and provider, such as their personal details, services offered, and payment details.
Individuals and providers who are providing services or receiving payments are required to file individual and provider specific information.
Individuals and providers can fill out the individual and provider specific information by providing accurate and up-to-date details about themselves and the services they provide.
The purpose of individual and provider specific information is to ensure transparency and accuracy in reporting of services provided and payments received.
Information such as personal details, services provided, payment details, and any other relevant information must be reported on individual and provider specific forms.
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