Common use of Requested Effective Date Clause in Contracts

Requested Effective Date. Date you are requesting to begin services. Please note, dates requested in excess of the date MC-19 is submitted must include written request with with supporting narrative. 4. Provider Name and Address: This is the address DHHS will use for correspondence. Enter the full name of the provider. When enrolling as an individual/solo practice or group member, enter the individual provider’s name AND title. When enrolling as a group practice, enter the group name. Enter the physical ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇▇, ▇▇▇▇▇, zip code + 4, your telephone and fax number, and an e-mail address to contact you. Also provide a contact name for the group, their title, phone and fax numbers. Note: A post office box without a physical location address will not be accepted. Each location must enroll separately. Each group member must enroll separately.

Requested Effective Date. Date you are requesting to begin services. Please note, dates requested in excess of the date MC-19 is submitted must include written request with with supporting narrative. 4. Provider Name and Address: This is the address DHHS will use for correspondence. Enter the full name of the provider. When enrolling as an individual/solo practice or group member, enter the individual provider’s name AND title. When enrolling as a group practice, enter the group name. Enter the physical ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇location address, ▇▇▇▇city, ▇▇▇▇▇state, zip code + 4, your telephone and fax number, and an e-mail address to contact you. Also provide a contact name for the group, their title, phone and fax numbers. Note: A post office box without a physical location address will not be accepted. Each location must enroll separately. Each group member must enroll separately.