Organization or Agency or Unit |
|
Point of Contact |
|
First Name |
|
Last Name |
|
Bill Phone |
x
|
Bill Fax |
x
|
Bill Email |
|
Billing Address |
|
Billing City |
|
Billing State |
|
Billing Postal Code |
|
National Provider Number #
(NPI is required for Medical Providers only.)
|
|
Contract Usage Agreement #
|
|
|
DES Contractor Preference (Please three contractors or more in the order of your preference.) |
1.
2.
3.
4.
5.
|
|
DSHS Contractor Preference (Please two contractors or more in the order of your preference.) |
1.
2.
3.
4.
5.
|