Get CA DHCS 9098 2010-2023
R) City State Nine-digit ZIP code Pay-to address (number, street, P.O. Box number) City State Nine-digit ZIP code Previous business address (number, street, P.O. Box number) City State Nine-digit ZIP code Taxpayer Identification Number** EXECUTION OF THIS PROVIDER AGREEMENT BETWEEN AN APPLICANT OR PROVIDER (HEREINAFTER JOINTLY REFERRED TO AS “PROVIDER”) AND THE DEPARTMENT OF HEALTH CARE SERVICES (HEREINAFTER “DHCS”), IS MANDATORY FOR PARTICIPATION OR CONTINUED PARTICIPATION .
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