AI- 74841
Purchasing Department 25.A.
CC REGULAR AGENDA SPECIAL MTG
Health & Human Services Dept.
- Meeting Date:
- 03/24/2020
- Submitted For:
- Marty Salazar
- Submitted By:
- Betsy Roque, PURCHASING DEPT.
- Department:
- PURCHASING DEPT.
Information
CAPTION
Requesting to approve an Amendment to the Provider/Network Participation Agreement to our existing agreement with Aetna, and other necessary documents as provided by the vendor.
BACKGROUND
Items provided by Aetna for completion:
- Provider Amendment
- Credentialing
- Ownership Disclosure (DOO)
- EFT Authorization
- ERA Authorization
- w9
- Provider-Group Data Application
Fiscal Impact
- CALENDAR YEAR:
- ACCT. #:
- FUNDS AVAILABLE Y/N?:
- MATCHING FUNDS Y/N?:
BUDGETARY IMPACT:
No fiscal impact.Attachments
- Notice of Provider Amendment
- Provider Amendment
- Credentialing Aetna Ownership Form
- EFT Authorization
- ERA Authorization
- Group Data Application
- Legal Approval
- 1295 Exemption
Form Review
| Inbox | Reviewed By | Date |
|---|---|---|
| Purchasing / Internal | msalazar | 03/20/2020 05:40 PM |
| Final Approval | Monica Salinas | 03/20/2020 05:40 PM |
- Form Started By:
- broque
- Started On:
- 03/13/2020 02:25 PM
- Final Approval Date:
- 03/20/2020