PAA7 REQUEST FOR PASSPORT AGREEMENT RENEWAL/EXPANSION Purpose of Request (check all that apply) 0 0 Renew provider agreement-same service Expand into another PAA. Note: Must be certified in another PAA. 0 Add or delete services (circle which) Certified in PAA _________________________________________ 0 DATE OF REQUEST: Change counties served (same PAA) PROVIDER NAME: DOING BUSINESS AS: OWNERSHIP TYPE: MEDICARE NUMBER: (circle) Private Charitable/Religious Public/govt Private/Non profit Other LEGAL STRUCTURE: GROUP SIZE: (circle) Corporation Non-profit corp Partnership S-Corp Sole Proprietorship Vol Corp GROUP TYPE: GROUP NUMBER: (circle) Corporation Group Medical Practice HMO Partnership Other TYPE: FED ID/SSN: (circle) PASSPORT Home Health Agency Phys Therapy Pharmacy Home Medical Supplier CORPORATE BUSINESS MAILING IN CARE OF: ADDRESS: PHONE: FAX: EMAIL: 0YES 0NO CHANGE IN OWNERSHIP? If please attach a separate statement “yes,” 0YES 0NO CHANGE IN governing body? If please attach a separate statement “yes,” 0YES 0NO CHANGE IN management or administration? If please attach a separate statement “yes,” Person authorized to sign provider agreement Name: Address: Title: Phone: Fax: Form completed by:______________________________________________________________________________ Date:_________________
PAA7 REQUEST FOR PASSPORT AGREEMENT RENEWAL/EXPANSION Purpose of Request (check all that apply) 0 Renew provider agreement-same service 0 Expand into another PAA. Note: Must be certified in another PAA. 0 Add or delete services (circle which) Certified in PAA _________________________________________ 0 Change counties served (same PAA) DATE OF REQUEST: PROVIDER NAME: DOING BUSINESS AS: OWNERSHIP TYPE: (circle) Private Charitable/Religious Public/govt Private/Non profit Other MEDICARE NUMBER: LEGAL STRUCTURE: (circle) Corporation Non-profit corp Partnership S-Corp Sole Proprietorship Vol Corp GROUP SIZE: GROUP TYPE: (circle) Corporation Group Medical Practice HMO Partnership Other GROUP NUMBER: TYPE: (circle) PASSPORT Home Health Agency Phys Therapy Pharmacy Home Medical Supplier FED ID/SSN: CORPORATE BUSINESS MAILING IN CARE OF: ADDRESS: PHONE: FAX: EMAIL: CHANGE IN OWNERSHIP? 0YES 0NO If “yes,” please attach a separate statement CHANGE IN governing body? 0YES 0NO If “yes,” please attach a separate statement CHANGE IN management or administration? 0YES 0NO If “yes,” please attach a separate statement Person authorized to sign provider agreement Name: Address: Title: Phone: Fax: Form completed by:______________________________________________________________________________ Date:_________________