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ILLINOIS DEPARTMENT OF HUMAN SERVICES BUREAU OF EARLY INTERVENTION EVALUATION/ASSESSMENT PORTFOLIO APPLICATION Name: Home Address: City: State:Zip Code:Phone #:Fax #:CFC's Serving:Credential: Credential
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01
Read the instructions and guidelines provided with the 04-16- provider agreement form.
02
Begin by filling out your personal and contact information, such as your name, address, phone number, and email.
03
Fill in the details of your organization or practice, including the name, address, and type of services provided.
04
Provide information about your professional qualifications and any certifications or licenses you hold.
05
Indicate whether you are applying as an individual provider or as part of a group practice.
06
Complete the sections related to your agreement and compliance with applicable laws and regulations.
07
Sign and date the provider agreement form, and ensure that all required fields are filled out accurately.
08
Submit the completed form to the relevant authority or organization as instructed.
09
Keep a copy of the filled-out provider agreement for your records.

Who needs 04-16- provider agreement for?

01
The 04-16- provider agreement form is needed by healthcare providers or organizations who wish to be contracted or affiliated with a specific authority or organization.
02
This could include individual healthcare professionals, group practices, hospitals, clinics, or other healthcare facilities.
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The 04-16- provider agreement is a document used to formalize the terms and conditions between a provider and a recipient of services.
Providers and recipients of services are required to file the 04-16- provider agreement.
To fill out the 04-16- provider agreement, both parties need to provide their contact information, details of the services to be provided, payment terms, and any other relevant terms.
The purpose of the 04-16- provider agreement is to establish a clear understanding of the services to be provided, the payment terms, and the responsibilities of both parties.
The 04-16- provider agreement must include information about the parties involved, the services to be provided, the payment terms, and any other relevant details.
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