CMS-10636 Provider HSD Table

Triennial Network Adequacy Review for Medicare Advantage Organizations and 1876 Cost Plans (CMS-10636)

MA_Provider_Table_Template NEW 508

Three-Year Network Adequacy Review for Medicare Advantage Organizations

OMB: 0938-1346

Document [pdf]
Download: pdf | pdf
*SSA State/County
Code

*Specialty Code

*National Provider
Identifier (NPI)
Number

*Name of Physician or
Mid-Level Practitioner

*Street Address

*City

*State

*ZIP Code

If PCP, Accepts New
Patients? (Y/N)

RPPO-Specific
Exception to Written
Agreements? (Y/N)

Letter of Intent? (Y/N)
Only applicable for
MA Applicants


File Typeapplication/pdf
File TitleHSD Table Templates
AuthorCGI Federal
File Modified2024:03:04 13:05:38-05:00
File Created2024:03:04 13:05:09-05:00

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