Enrollment Forms - JF Part A
Enrollment Forms
- Attachment B - Community Mental Health Center Site Visit Request
- Provider Enrollment CAP Reconsideration Coversheet
- CMS 588 - Authorization Agreement for Electronic Funds Transfer (EFT)
- CMS 855A - Institutional Providers
- CMS Exhibit 178 and 177 - Federally Qualified Health Centers (FQHCs)
- CMS Exhibit 275 - Attestation Statement for Community Mental Health Centers (CMHCs)
- CMS Exhibit 282 - Community Mental Health Centers
- CMS Provider-Based Status Attestation Statement (sample)
- Rebuttal Coversheet
- Supplemental Facility-Based/Fiscal Year Request Statement
- Supplemental Facility-Based/Fiscal Year Request Statement Instructions
Se ha producido un error al procesar la plantilla.
Java method "com.liferay.portal.kernel.util.DateUtil_IW.parseDate(String, String, Locale)" threw an exception when invoked on com.liferay.portal.kernel.util.DateUtil_IW object "com.liferay.portal.kernel.util.DateUtil_IW@1630a0cf"; see cause exception in the Java stack trace.
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FTL stack trace ("~" means nesting-related):
- Failed at: #assign norModifieddateObj = dateUtil... [in template "medicare-velocity-templates-theme_SERVLET_CONTEXT_/templates/freemarker/content/free-form-text.ftl" at line 11, column 5]
- Reached through: #include "medicare-velocity-templates... [in template "10155#10193#74691" at line 1, column 1]
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1<#include "medicare-velocity-templates-theme_SERVLET_CONTEXT_/templates/freemarker/content/free-form-text.ftl">
