Form SFN1169 Pharmacy Agreement / Medical Assistance Program - North Dakota

What Is Form SFN1169?

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 SFN1169 Pharmacy Agreement/Medical Assistance Program?
A: Form SFN1169 is a pharmacy agreement for the Medical Assistance Program in North Dakota.

Q: Who is it for?
A: It is for pharmacies who wish to participate in the Medical Assistance Program in North Dakota.

Q: What is the purpose of this form?
A: The purpose of this form is to establish an agreement between the pharmacy and the Medical Assistance Program.

Q: What information is required on this form?
A: The form requires information such as the pharmacy's name, address, contact information, and Medicaid provider number.

Q: Is there a fee to submit this form?
A: No, there is no fee to submit this form.

Q: Are there any additional requirements to participate in the Medical Assistance Program?
A: Yes, pharmacies must meet certain eligibility criteria and comply with all program rules and regulations.

Q: What happens after I submit this form?
A: Once the form is submitted and approved, the pharmacy will be able to provide prescription drugs to eligible Medical Assistance Program recipients.

Q: What if I have questions or need assistance with this form?
A: If you have any questions or need assistance, you can contact the North Dakota Department of Human Services or your local Medicaid office.