"North Dakota Medicaid Provider Enrollment Attestation Licensed Associate Professional Counselor" - North Dakota

North Dakota Medicaid Provider Enrollment Attestation Licensed Associate Professional Counselor is a legal document that was released by the North Dakota Department of Human Services - a government authority operating within North Dakota.

Form Details:

  • Released on December 31, 2019;
  • The latest edition currently provided by the North Dakota Department of Human Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the North Dakota Department of Human Services.

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North Dakota Medicaid Provider Enrollment Attestation
Licensed Associate Professional Counselor
Practitioner Name (printed)
NPI
As an LAPC enrolling to provide services under the North Dakota Rehabilitative Services
State Plan, I attest that I provide only the following service/s:
CHECK ALL THAT APPLY
Forensic Interview
Individual Counseling
Intensive In-Home for Children
Skills Integration
Behavioral Health Counseling and Therapy (QRTP only)
I attest that I will provide only the above service/s in accordance with the North
Dakota Rehabilitative Services State Plan.
Signature of Enrolling Practitioner
Date
Provider Facility/Organization to complete:
I attest that the practitioner mentioned above will only provide the service(s) marked
above in accordance with the North Dakota Rehabilitative State Plan.
Provider Facility/Organization Name
Street Address
City, State, Zip Code
Signature of Authorized Representative
Date
Printed Name of Authorized Representative
Please sign and return by Email to
dhsenrollment@nd.gov or by
fax to 701-328-4030,
Attention: Provider Enrollment
Revision Date 12/31/2019 JS
North Dakota Medicaid Provider Enrollment Attestation
Licensed Associate Professional Counselor
Practitioner Name (printed)
NPI
As an LAPC enrolling to provide services under the North Dakota Rehabilitative Services
State Plan, I attest that I provide only the following service/s:
CHECK ALL THAT APPLY
Forensic Interview
Individual Counseling
Intensive In-Home for Children
Skills Integration
Behavioral Health Counseling and Therapy (QRTP only)
I attest that I will provide only the above service/s in accordance with the North
Dakota Rehabilitative Services State Plan.
Signature of Enrolling Practitioner
Date
Provider Facility/Organization to complete:
I attest that the practitioner mentioned above will only provide the service(s) marked
above in accordance with the North Dakota Rehabilitative State Plan.
Provider Facility/Organization Name
Street Address
City, State, Zip Code
Signature of Authorized Representative
Date
Printed Name of Authorized Representative
Please sign and return by Email to
dhsenrollment@nd.gov or by
fax to 701-328-4030,
Attention: Provider Enrollment
Revision Date 12/31/2019 JS