Fully executed agreement - Laserfiche WebLink

Home Browse Search

PARTICIPATING PROVII}ER AGREEMENT SCHEDIILE C INFORMATION FOR COMRACTED PROVIDERS Provider shall provide Health Plan with the information sEt forth beiow with respect to: (i) Provider; (ii) each Conhacted Provider; and (iiD ifapplicabie, each Contracted Provider's locations and/or professionals. To the extent Provider provides the narne of any Contracted Provider to Health Plan hereunder, such entity andlor individual will be considered a Contracted Provider rurder this Agreernent regardle.ss of whether the complete list of information set forth below relating to such Contracted Provider is provided by Provider. L Name 2. Address 3. E-mail address 4, Telephone and facsimile numbers 5. Professional license numbers 6. Medicare/IVledicaid ID numbers 7. Federal ta:c ID numbers 8. CompletedW-9 form 9, National Provider Iclentifier (NPI) numbers 10. Provider Taxonomy Codes 11. Area of medical specialty 12. Age r-estrictions (if any) 13. Area hospitals with admitting privileges (where applicable) 14. Whether Providers are employed or subcontrasted with Conhacted Provider using the designation *E' fur enrployed or'oC" for subcontracted. 15. For a subcontracted Provider, whether its Providers are e,mployed or contracted with the subcontraoted Provider using the designation'D" for employed or "C" for contracted. 16. Office contact percon 17. Office hours 18. Billing oftrce 19. Billing office address 20. Billing ofiice telephone and facsimile nurrbers 2i. Billing office e-mail address 22. Biiling office contact person. 23. Ownsrship Disclosure Fonn, as roquired 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 - Kittitas County Pubtic Health . 05.07.2025 - ICMProviderAgreemenr_360268 Page24of24