Fillable SchoolBasedBusTransportation - Provider Profiles_1

Fill Online, Printable, Fillable, Blank SchoolBasedBusTransportation - Provider Profiles_1 Form

Use Fill to complete blank online ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AZ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

SchoolBasedBusTransportation - Provider Profiles_1

On average this form takes 1 minutes to complete

The SchoolBasedBusTransportation - Provider Profiles_1 form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 3 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Arizona Health Care Cost Containment System

BROWSE ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AZ) 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
 
PROVIDER TYPE PROFILE
PROVIDER
TYPE
92
SCHOOL BASED BUS TRANSPORTATION
REIMBURSE-
MENT TYPE
02 FEE FOR SERVICE-BILLABLE TO THE TPA
EFFECTIVE 07/01/00
CATEGORIES OF SERVICE LICENSE/CERTIFICATION
MANDATORY 31
NON-EMERGENCY
TRANSPORTATION
PROOF OF VEHICLE INSURANCE
MANDATORY
MANDATORY
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
SPECIAL INSTRUCTIONS: The School District is responsible for maintaining and providing upon
request a valid Arizona Driver’s license for each driver and proof of insurance. By signing below you are
indicating that this information will be kept on file and made available upon request.
School District ____________________________ ID Number: ___________________________
Signature: __________________________________ Date: __________________________
SPECIAL INSTRUCATIONS: REIMBURSEMENT ONLY TO SCHOOL DISTRICTS. MUST HAVE PAY-
TO ADDRESS TO SCHOOL DISTRICTS AND/OR GROUP AFFILIATION WITH SCHOOL DISTRICT
GROUP BILLER.
Revised 05/04/2017
RESET
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

SchoolBasedBusTransportation - Provider Profiles_1

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 9 February 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document