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Get NE DHHS MC-19 2010-2024

R OR for individual providers, do you attest that you are in the United States legally and eligible to work per Pub.L. no. 104-193 (1997)?  Yes  No MC-19 Page 2 Section B: Individual Professionals Part of Provider Group Complete for each individual professional that is part of the group provider and subject to the group service provider agreement. ATTACH ADDITIONAL PAGES AS NECESSARY. INDIVIDUAL #1 1. Licensee Full Name and Title 2. Provider Type 3. Provider Speciality 5. National Pr.

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