Fillable National Disaster Medical System Definitive Care Reimbursement Program (Assistant Secretary for Preparedness and Response)

Fill Online, Printable, Fillable, Blank National Disaster Medical System Definitive Care Reimbursement Program (Assistant Secretary for Preparedness and Response) Form

Use Fill to complete blank online ASSISTANT SECRETARY FOR PREPAREDNESS AND RESPONSE (DC) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

National Disaster Medical System Definitive Care Reimbursement Program (Assistant Secretary for Preparedness and Response)

On average this form takes 6 minutes to complete

The National Disaster Medical System Definitive Care Reimbursement Program (Assistant Secretary for Preparedness and Response) form is 2 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 20 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Assistant Secretary for Preparedness and Response

BROWSE ASSISTANT SECRETARY FOR PREPAREDNESS AND RESPONSE (DC) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
National Disaster Medical System
Definitive Care Reimbursement Program
Provider Enrollment Form
Legal Name of Business or Individual:
Trade or “D/B/A” Name if applicable:
IRS Employer Identification Number (EIN):
Physical Street Address:
City, State and Zip Code:
National Provider Identifier (NPI) Number:
Medicaid Provider Number and State:
Medicare Provider Number (CMS Certification Number CCN):
Contact Person:
Contact Person Company Name:
Is the Contact Person with a 3
rd
Party Billing Service?:
Contact Person’s Phone Number:
Contact Person’s Fax Number:
Contact Person’s E-mail Address:
Contact Person’s Mailing Address:
Contact Person’s City, State and Zip Code:
Apprio Inc.
Page 1 of 2
No
Authorization:
By your signature on this form you are certifying that the account is drawn in the Name of the
Physician or Individual Practitioner, or the Legal Business Name of the Provider or Supplier. All
arrangements between the Financial Institution and the said Provider or Supplier are in
accordance with all applicable regulations and instructions with the effective date of the EFT
authorization. You must notify Apprio Inc. regarding any changes in the account in sufficient
time to allow Apprio Inc. to act on the changes.
Authorized/Delegated Official Name:
Authorized/Delegated Official Telephone #:
Authorized/Delegated Official Title:
Authorized/Delegated Official E-mail Address:
Authorized/Delegated Official Signature:
Date Signed:
Please mail or fax this completed form along with the ACH Vendor Enrollment form to:
Apprio Inc.
NDMS Definitive Care Reimbursement Program
425 3rd Street, SW
Suite 600
Washington, DC 20024
Fax: 888.587.2352
Apprio Inc.
Page 2 of 2
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

National Disaster Medical System Definitive Care Reimbursement Program (Assistant Secretary for Preparedness and Response)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 7 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document