10-Form 09-Entity Headquarters Info-Location(s) (VR 3441C).pdf

PDF 132 KB Posted

Attached to
3202600156 Open Enrollment (OE) for Diabetes Self-Management Education Services
Solicitation number
3202600156
Issued by
Texas

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Other files

File Type Posted
9-Form 10-Entity’s Physical Location(s) Part A (VR 3442A).pdf PDF
19-Form 07-Entity Headquarters Info Management Form (VR 3441A).pdf PDF
1-Attachment 06-VR2901 Diabetes Self-Management Education.pdf PDF
7-Form 08-Entity Headquarters Information-Services (VR 3441B).pdf PDF
15-Attachment 01-VR OE TCs (12-18-2025).pdf PDF
12-Form 06-Provider Insurance Verification (VR 3445).pdf PDF
20-Form 11-Entity’s Physical Location(s) Part B (VR3442B).pdf PDF
8-Form 05-Conflict of Interest Certification (VR 3444).pdf PDF
4-Attachment 07-VR3455 Provider Staff Information Form.pdf PDF
23-Open Enrollment (OE) Diabetes Self-Management 3202600156.pdf PDF
5-Attachment 09-VR3490 Temporary Waiver of Qualifications.pdf PDF
22-Form 03-Child Support Certification (VR 1305).pdf PDF
6-Attachment 08-VR3472 Contracted Service Modification Req.pdf PDF
2-Attachment 02-OE Application Submission Checklist.pdf PDF
14-Attachment 03-VR2884 Diabetes Self-Management Educator.pdf PDF
11-Form 12-Provider Staff Information Form (VR 3455).pdf PDF
17-Form 02-W-9 and Direct Deposit Form (VR1020).pdf PDF
13-Attachment 10-VR5000 Referral for Provider Services.pdf PDF
3-Attachment 05-VR2900 Diabetes Self-Management Education.pdf PDF
16-Attachment 04-VR2888 Diabetes Self-Management Education Assessment.pdf PDF
21-Form 04-TWC VR Standards for Providers Certification (VR 3443).pdf PDF
18-Form 01-Execution of Application.pdf PDF
Show all 22

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