Stabilization Payment Request
Provider Information
Provider Name
*
EIN
*
NPI
*
Contact name
*
Contact Email
*
Contact Phone Number
Phone
Disruption to Service Delivery
Service Location
*
Service Location a Designated Disaster Area?
*
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Program Type
*
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Other Program Type Description
Efforts to minimize the impact of Disaster
Number of Members Impacted
*
Timeframe of Anticipated Disruption to Member Care
Disaster Expense Reimbursement
Please Attach Disaster Expense Report (if applicable)
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