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For Fiscal Agent Use Managed Care Treating Provider Registration Providers who are not already enrolled with the Florida Medicaid program and who perform services for Florida Medicaid eligible recipients under a Medicaid capitated managed care organization MCO may submit this form to obtain a Florida Medicaid provider ID. Name of MCO Home/Corp Office Address Medicaid ID MCO ATTESTATION On behalf of the Medicaid MCO named in this registration I at.

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Specific qualifications for each provider type are listed in the Provider Permission Matrix. If you have any questions regarding completion of the Provider Enrollment Online Application, please contact the CSRA Call Center by phone—800-688-6696, fax—855-710-1965, or email—NCTracksprovider@nctracks.com.

a. A valid North Carolina drivers' license or other identification card issued by the North Carolina Division of Motor Vehicles. b. A current North Carolina rent, lease, or mortgage payment receipt, or current utility bill in the name of the applicant or the applicant's legal spouse, showing a North Carolina address.

The county department of social services shall render a decision on an individual's application for Medicaid within 45 calendar days from the date of application, except for applications in which a disability determination has already been made or is needed.

Usually, the North Carolina Medicaid application fee is $100.00 and covers the costs associated with processing the enrollment application. The federal fee covers the costs associated with screening.

Verify eligibility, health plan and primary care provider enrollment using the NCTracks Recipient Eligibility Verification/Response or calling the NCTracks Call Center for more information: 800-688-6696.

CMS 855A. Form Title. Medicare Enrollment Application - Institutional Providers.

Eligibility Provide services to at least one North Dakota Medicaid eligible recipient. Meet the conditions regulating the specific type of provider, program, and/or service. Hold a current license, certification, accreditation, or registration ing to North Dakota state laws and regulations.

NC Medicaid offers providers a secure and convenient method to complete and submit enrollment applications through the NCTracks Provider Portal. Providers have the ability to complete the application online as well as electronically sign and submit the application through the portal.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232