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Tax & Finance
Hs 215a - Fill Online, Printable, Fillable, Blank | PDFfiller
Officers directors purchase of stock etc. as required by law even though no change in legal ownership is occurring. Refer to the INSTRUCTION SHEET. Facility name Facility address number street city Type of Facility HHA ICF SNF OTHER FACILITY TYPE explain Type of Business Entity For EACH business entity identify the name EIN of the entity Corporation Individual LLC Management Company Partnership OTHER Business Entity...
Fillable Online Hs 215a applicant individual information - US-State ...
OMB: Page 1. HS 215A APPLICANT INDIVIDUAL INFORMATION (CALIFORNIA FORM). CALIFORNIA: DEPARTMENT OF HEALTH AND HUMAN SERVICES: ...
Fillable Online cdph ca AFL-06-16 - California Department of Public ...
... 2006 AFL 06-16 TO: ALL Facilities SUBJECT: FORM HS 215A (7/06) APPLICANT INDIVIDUAL INFORMATION The California Department of Health Services ...
Bcia 8016 - Fill Online, Printable, Fillable, Blank | PDFfiller
Code five-digit code assigned by DOJ Street Address or P. O. Box Contact Name mandatory for all school submissions City State ZIP Code Contact Telephone Number Applicant Information Last Name First Name Other Name AKA or Alias Last First Sex Date of Birth Height Place of Birth State or Country Male Eye Color Female Hair Color Social Security Number Middle Initial Suffix Driver s License Number Billing Number Misc*...
Dhcs 9098 - Fill Online, Printable, Fillable, Blank | PDFfiller
Not to submit any treatment authorization requests TARs or claims to DHCS using an NPI unless that NPI is appropriately registered for this provider with the Centers for Medicare and Medicaid Services CMS and is in compliance with all NPI requirements established by CMS as of the date the claim is submitted. Provider agrees that submission of an NPI to DHCS as part of an application to use that NPI to obtain payment...
Information Request Medicare - Fill Online, Printable, Fillable, Blank ...
Department along with your other Medicare application materials. I. Healthcare Provider Information CMS Medicare Provider Number Name of Facility Address Street Number and Name City or Town Administrator s Name Telephone FAX Type of Facility Corporate Affiliation State or Province - Contact Person TDD E-mail Zip Code Number of employees Reason for Application Circle One Initial Medicare Certification or Change of...
Hhs 690 Form - Fill Online, Printable, Fillable, Blank | PDFfiller
Other Federal financial assistance from the U.S. Department of Health and Human Services. THE APPLICANT HEREBY AGREES THAT IT WILL COMPLY WITH 1. Title VI of the Civil Rights Act of 1964 Pub. THE APPLICANT HEREBY AGREES THAT IT WILL COMPLY WITH 1. Title VI of the Civil Rights Act of 1964 Pub. L* 88-352 as amended and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human...
Get cms588 2013-2017 form - PDFfiller
Payment via electronic funds transfer. EFT enrollment does not constitute enrollment as a provider or supplier in the Medicare program. Form CMS-588 09/13 PART IV CONTACT PERSON Contact Person s Name PART V AUTHORIZATION I hereby authorize the Centers for Medicare Medicaid Services CMS to initiate credit entries and in accordance with 31 CFR part 210. Zeros. Select the account type. If you do not submit this...
Licensee has their permission to use the current licensee s Program Plan for up to 6 months if applicable. Program Plan -- Only applies to ICF/DD ICF/DD-H and ICF/DD-N H S Code Section 1275. 3 b 3 Has the program plan been approved by the Department of Developmental Services be used for 6 months if they submit a letter to CDPH. If no the application package will be delayed until a copy of the approved program...
Insurance Agreement - Fill Online, Printable, Fillable, Blank | PDFfiller
Under title XVIII of the Social Security Act D/B/A as the provider of services agrees to conform to the provisions of section of 1866 of the Social Security Act and applicable provisions in 42 CFR. This agreement upon submission by the provider of services of acceptable assurance of compliance with title VI of the Civil Rights Act of 1964 section 504 of the Rehabilitation Act of 1973 as amended and upon acceptance...
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