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This version of the form is not currently in use and is provided for reference only. Download this version of
Form SFN615
for the current year.
Form SFN615 Medicaid Program Provider Agreement - North Dakota
What Is Form SFN615?
This is a legal form that was released by the North Dakota Department of Health and Human Services - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form SFN615?
A: Form SFN615 is a Medicaid Program Provider Agreement specific to North Dakota.
Q: Who is required to fill out Form SFN615?
A: Healthcare providers who wish to participate in the Medicaid Program in North Dakota are required to fill out Form SFN615.
Q: What is the purpose of Form SFN615?
A: The purpose of Form SFN615 is to establish an agreement between the healthcare provider and the North Dakota Medicaid Program.
Q: What information is required on Form SFN615?
A: Form SFN615 requires the provider's business information, Medicaid provider number, services offered, billing information, and agreement terms.
Q: Is Form SFN615 specific to North Dakota?
A: Yes, Form SFN615 is specific to the Medicaid Program in North Dakota and may not be applicable in other states.
Form Details:
- Released on November 1, 2017;
- The latest edition provided by the North Dakota Department of Health and Human Services;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form SFN615 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health and Human Services.
Download Form SFN615 Medicaid Program Provider Agreement - North Dakota
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