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Get DISCLOSURE FORM FOR A PROVIDER PERSON I ... - TN.gov - Tn

Revised 3/9/12 Page 1 of 5 DISCLOSURE FORM FOR A PROVIDER PERSON Directions Use this form if you are trying to get a TennCare/Medicaid provider ID number for a Provider Person. If the addition of the Provider Person will change the Ownership or Control structure of the Provider Entity that the Provider Person is joining i.e. the new Provider Person will also be an owner or high ranking employee of the Provider Entity then you must also fill out a.

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