SHJ25-008 COORDINATED CARE CONTRACT - PARTIALLY EXECUTED

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PARTICIPATING PROVIDER AGREEMENT SCHEDULE C INFORMATION FOR CONTRACTED PROVIDERS Provider shall provide Health Plan with the information set forth below with respect to: (i) Provider; (ii) each Contracted Provider; and (iii) if applicable, each Contracted Provider's locations and/or professionals. To the extent Provider provides the name of any Contracted Provider to Health Plan hereunder, such entity and/or individual will be considered a Contracted Provider under this Agreement regardless of whether the complete list of information set forth below relating to such Contracted Provider is provided by Provider. 1. Name 2. Address 3. E-mail address 4. Telephone and facsimile numbers 5. Professional license numbers 6. Medicare/Medicaid ID numbers 7. Federal tax ID numbers 8. Completed W-9 form 9. National Provider Identifier (NPI) numbers 10. Provider Taxonomy Codes 11. Area of medical specialty 12. Age restrictions (if any) 13. Area hospitals with admitting privileges (where applicable) 14. Whether Providers are employed or subcontracted with Contracted Provider using the designation "B" for employed or "C" for subcontracted. 15. For a subcontracted Provider, whether its Providers are employed or contracted with the subcontracted Provider using the designation "E" for employed or "C" for contracted. 16. Office contact person 17. Office hours 18. Billing office 19. Billing office address 20. Billing office telephone and facsimile numbers 21. Billing office e-mail address 22. Billing office contact person 23. Ownership Disclosure Form, as required to comply with Regulatory Requirements and Governmental Contract NOTE: For a complete listing of the information and additional documentation required, please refer to the enrollment application. PPA WA - Kinitas County Public Health - 05.07.2025 - ICMProviderAgreement_360268 Page 24 of 24