DSHS Form 10-664 "New or Update Provider Information Worksheet" - Washington

What Is DSHS Form 10-664?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2021;
  • The latest edition provided by the Washington State Department of Social and Health 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 printable version of DSHS Form 10-664 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 10-664 "New or Update Provider Information Worksheet" - Washington

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DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA)
New or Update Provider Information Worksheet
REGION
COUNTY
CONTRACT NUMBER
PROVIDER’S NAME
PROGRAM NAME
PROVIDER’S NUMBER OR NPI
PROGRAM TYPE
SL
RHC
GH
SOLA
CH
ICF/MR
LSR
Mailing Address
STREET / POST OFFICE BOX
CITY
STATE
ZIP CODE
Physical Address
STREET
CITY
STATE
ZIP CODE
Contact Information
TELEPHONE NUMBER (INCLUDING AREA CODE)
FAX NUMBER
EMAIL ADDRESS
ADMINISTRATOR’S NAME
TELEPHONE NUMBER (INCLUDING AREA CODE)
FAX NUMBER
EMAIL ADDRESS
FINANCE / PREPARER’S NAME
TELEPHONE NUMBER (INCLUDING AREA CODE)
FAX NUMBER
EMAIL ADDRESS
Business Information
FEDERAL ID NUMBER
FACILITY OR NON-FACILITY
PROGRAM CAPACITY
NUMBER OF FT EMPLOYEES
BUSINESS TYPE
Sole Proprietor
State Owned / Operated
Non-Profit Corporation
Governmental
Proprietary Corporation
RM Information
What date do you want access to the program in RRDD to create your RCR?
NEW OR UPDATE PROVIDER INFORMATION WORKSHEET
DSHS 10-664 (REV. 11/2021)
DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA)
New or Update Provider Information Worksheet
REGION
COUNTY
CONTRACT NUMBER
PROVIDER’S NAME
PROGRAM NAME
PROVIDER’S NUMBER OR NPI
PROGRAM TYPE
SL
RHC
GH
SOLA
CH
ICF/MR
LSR
Mailing Address
STREET / POST OFFICE BOX
CITY
STATE
ZIP CODE
Physical Address
STREET
CITY
STATE
ZIP CODE
Contact Information
TELEPHONE NUMBER (INCLUDING AREA CODE)
FAX NUMBER
EMAIL ADDRESS
ADMINISTRATOR’S NAME
TELEPHONE NUMBER (INCLUDING AREA CODE)
FAX NUMBER
EMAIL ADDRESS
FINANCE / PREPARER’S NAME
TELEPHONE NUMBER (INCLUDING AREA CODE)
FAX NUMBER
EMAIL ADDRESS
Business Information
FEDERAL ID NUMBER
FACILITY OR NON-FACILITY
PROGRAM CAPACITY
NUMBER OF FT EMPLOYEES
BUSINESS TYPE
Sole Proprietor
State Owned / Operated
Non-Profit Corporation
Governmental
Proprietary Corporation
RM Information
What date do you want access to the program in RRDD to create your RCR?
NEW OR UPDATE PROVIDER INFORMATION WORKSHEET
DSHS 10-664 (REV. 11/2021)