WA Contact/Profile Update Form
WA Medicaid Reimbursement Program Contact/Profile Update
|Leader uses this form to add your school district’s contact information to our Medicaid Reimbursement participant tracking system. This ensures that the necessary |
|program information, forms, and reports are forwarded to the correct contact person. School districts also can use this form to update their personnel or contact |
|information as changes occur. Fax the completed form to Leader at (570) 454-0162 or mail it to P.O. Box O, Hazleton, PA 18201. |
|1. School District Address | |
|(U.S. postal address) | |
| |Education agency name |
| | |
| |Street address #1 |
| | |
| |Street address #2 | | | | |
| | | | | | |
| |City | State ZIP+4 |
| | | |
| |Phone (include area code) | |Fax (include area code) |
| |
|2. Federal Express/UPS Shipping Address | |
|(Please no PO box numbers) | |
| | |
|Complete this section only if the shipping address differs from the U.S. | |
|Postal mailing address shown above. | |
| |Street address #1 |
| | |
| |Street address #2 | | |
| | | | | |
| |City | |State | ZIP+4 |
| |
|3. Special Education Director | |
|Check one | Dr. | Mr. | Mrs. | Ms. | |Provide only address or contact information that differs from the school district |
| | | | | | |mailing address. |
| | | | | |
|First name | |MI |Street address #1 |
| | | | |
|Last name | | |Street address #2 | | | |
| | | | | | | |
|E-mail address | | |City | |State ZIP+4 |
| | | | | | |
| | | |Phone (include area code) | |Fax (include area code) |
|4. Medicaid Reimbursement Coordinator | |
|Check one | Dr. | Mr. | Mrs. | Ms. | |Provide only address or contact information that differs from the school district |
| | | | | | |mailing address. |
| | | | | |
|First name | |MI |Street address #1 |
| | | | |
|Last name | | |Street address #2 | | | |
| | | | | | | |
|E-mail address | | |City | |State ZIP+4 |
| | | | | | |
| | | |Phone (include area code) | |Fax (include area code) |
more on reverse
WA Medicaid Reimbursement Program Contact/Profile Update, page 2
|5. Report Recipient | |
|Check one | Dr. | Mr. | Mrs. | Ms. | |Provide only address or contact information that differs from the school district |
| | | | | | |mailing address. |
| | | | | |
|First name | |MI |Street address #1 |
| | | | |
|Last name | | |Street address #2 | | | |
| | | | | | | |
|E-mail address | | |City | |State ZIP+4 |
| | | | | | |
| | | |Phone (include area code) | |Fax (include area code) |
|6. Business Manager (fiscal contact) | |
|Check one | Dr. | Mr. | Mrs. | Ms. | |Provide only address or contact information that differs from the school district |
| | | | | | |mailing address. |
| | | | | |
|First name | |MI |Street address #1 |
| | | | |
|Last name | | |Street address #2 | | | |
| | | | | | | |
|E-mail address | | |City | |State ZIP+4 |
| | | | | | |
| | | |Phone (include area code) | |Fax (include area code) |
|7. Procedures Manual Recipient | |
|Check one | Dr. | Mr. | Mrs. | Ms. | |Provide only address or contact information that differs from the school district |
| | | | | | |mailing address. |
| | | | | |
|First name | |MI |Street address #1 |
| | | | |
|Last name | | |Street address #2 | | | |
| | | | | | | |
|E-mail address | | |City | |State ZIP+4 |
| | | | | | |
| | | |Phone (include area code) | |Fax (include area code) |
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