It Is Critical to Lme/Mco That You Complete All Data Please Print Or Type

ALLIANCE BEHAVIORAL HEALTHCARE

VENDOR PROFILE FORM

IT IS CRITICAL TO LME/MCO THAT YOU COMPLETE ALL DATA – PLEASE PRINT OR TYPE

(A W-9 FORM & EFT Authorization Form IS REQUIRED AND MUST BE SUBMITTED WITH THIS FORM)

Legal Name (As registered with the Secretary of State): Click here to enter text.

Doing Business As: Click here to enter text.

Corporate Headquarters Address: Click here to enter text.

Mailing Address: Click here to enter text.

Billing Address: Click here to enter text.

Provider Website Address (URL): Click here to enter text.

Service Site(s) (address other than Corporate Headquarters):

1)  Click here to enter text. 2) Click here to enter text.

(use additional sheet if needed)

Telephone: Click here to enter text. Fax: Click here to enter text.

Emergency Phone Number: Click here to enter text. Federal Tax ID No: Click here to enter text.

Medicaid ID No: Click here to enter text. NPI No: Click here to enter text.

Do you require a 1099? Yes No

Business Type (check all applicable boxes):

C-Corp. S-Corp. LLC General Partnership Sole Proprietorship Limited Partnership

PC LLP Governmental Agency Profit Non-Profit

Other Contracting LMEs: Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Executive Director (Name): Phone: ( ) - Cell: ( ) -

E-mail Address: Click here to enter text.

Program Director (Name): Phone: ( ) - Cell: ( ) -

E-mail Address: Click here to enter text.

Accounting Contact (Name): Phone: ( ) - Cell: ( ) -

E-mail Address: Click here to enter text.

Practitioner/LPs (Name): Phone: ( ) - Cell: ( ) -

E-mail Address: Click here to enter text.

(use additional sheet if needed)

List names of those with authority to sign billings and receive payments, including name, title, e-mail, and telephone number:

Name: Title: Phone: ( ) -

E-Mail Address:

Name: Title: Phone: ( ) -

E-Mail Address:

Name: Title: Phone: ( ) -

E-Mail Address:

Signature: ______Title: ______

Print name: ______Date: ______

Return to Contracts, 4600 Emperor Blvd, Suite 200 Durham, NC 27703 or fax to 919-651-8672

Revised 8/2013