Sample Signature Log - Wa
School-Based Health Care Services (SBHS)
Sample Provider Signature Log
Directions: Use this form to list all qualified health care providers for your school district. Include the provider’s printed name, handwritten signature(s), initials, credentials, license number and National Provider Identifier (NPI). If a provider has various signatures, all versions of the signature should be included on the signature log. This form does not need to be provided to the SBHS program manager but must be kept on file and must be made available for monitoring activities per WAC 182-537-0700 and WAC 182-502A.
|School District Name |Phone |Fax |
|Address |School District Billing NPI |
|Verified and signed by director or designee |Date |School Year |
|Servicing Provider Name |Printed Name |Signature(s) |Initials |Credentials |License |NPI |
| | | | | |Number | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
-----------------------
Revised 9/17
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- safe schools action pack 4 children s activities living
- state of maine
- risk assessment template hse information about health
- health social care and children s services
- emergency action plan template
- emergency preparedness and response plan
- sample signature log wa
- nmc revalidation combined forms and templates
- point of dispensing pod site plan template
- treatment plan goals objectives
Related searches
- 2401 utah ave south seattle wa 98134
- wa state report card
- starbucks seattle wa headquarters
- visa signature card log in
- ospi wa state report card
- wa state dept lic
- starbucks seattle wa corporate
- university place wa school schedule
- wa department of lic
- wa ospi report card
- get wa state tuition
- wa state business lookup