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HCAS Provider Enrollment Form. HCAS Provider Enrollment form DATE COMPLETED BY TELEPHONE Provider Information Provider Name (First, Middle, Last, Suffix) Degree/Title Specialty/Sub-specialty CAQH ID Social Security Number Date of Birth License # DEA # Gender: M F PCP Specialist Both National Provider Identifier (NPI) Medicare/Medicaid # Primary Hospital Affiliation Staff Position Please ... Page v Enrollment Application Instructions Rev. XXXVII Revised 12/18/2017 EThective 01/01/2018 Out-of-State Incorporated Providers If the enrolling provider is incorporated in another state, the following additional forms must be submitted: • Corporate Board of Directors Resolution Form.1a. Tap the syringe at least 10 times to dislodge any material that may have settled. 1b. Then after tapping, shake the syringe vigorously for a minimum of 30 seconds to ensure …Get the best of Shopping and Entertainment with Prime. Enjoy low prices and great deals on the largest selection of everyday essentials and other products, including fashion, home, beauty, electronics, Alexa Devices, sporting goods, toys, automotive, pets, baby, books, video games, musical instruments, office supplies, and more.

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