PROVIDER / VENDOR INTAKE FORM
Date completed
-
Month
-
Day
Year
Date
PARTICIPANT INFORMATION
Who is Filling out Form?
Participant
Participant's Authorized Representative
Vendor/Provider
Authorized Representative Name
First Name
Last Name
Authorized Representative Relationship
Did you complete the participant intake form?
*
Yes
Not yet, but I will do next
Did the participant complete their intake form?
*
Yes
Not sure
Participant Name
First Name
Last Name
Participant UCI
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PROVIDER /VENDOR INFORMATION
Company name
*
Point of Contact Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Are there multiple services?
Yes
No
Service Code
Please Select
310
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338
Select Service Codes
310
311
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320
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Requirements to be a Vendor for Amico FMS
Each vendor will be required to provide a current business license and/or professional certification, Form-W9, and Direct Deposit Form. Each vendor will also be required to complete a Vendor Provider Agreement.
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Open Dropdown to add additional Vendors
Do you have another vendor?
Yes
No
Vendor #2
Company name
Point of Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Select Service Codes
310
311
312
313
320
321
322
323
324
325
330
331
333
334
335
338
340
358
365
366
367
Vendor #3
Company name
Point of Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Select Service Codes
310
311
312
313
320
321
322
323
324
325
330
331
333
334
335
338
Vendor #4
Company name
Point of Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Select Service Codes
310
311
312
313
320
321
322
323
324
325
330
331
333
334
335
338
340
358
365
366
367
Vendor #5
Company name
Point of Contact Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Select Service Codes
310
311
312
313
320
321
322
323
324
325
330
331
333
334
335
338
340
358
365
366
367
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Auth Token
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Document Type
patient
Submission Type
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