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Encounter Data Signature Authorization Form - Nc Department Of Health And Human Services

Encounter Data Signature Authorization Form

Contracted Plan Name:__________________________ NPI Number:__________________________

Encounter Data transaction information submitted to DMA must be certified by one of the following:

Chief Executive Officer (CEO)

Chief Financial Officer (CFO); or

Any individual who has delegated authority to sign for and reports directly to the CEO or CFO.

___________________________________

Print Name of CEO/CFO

Print Title of CEO/CFO

___________________________________

Signature

Date

As CEO/CFO I authorize the following designated person to certify encounter data transactions:

Full name and title of the person other than the CEO/CFO identified above who has delegated authority

to sign for and who reports directly to the CEO/CFO, and to certify the data and information submitted

to NC DMA.

___________________________________

Print Name

Print Title

___________________________________

Signature

Date

Please submit more than one form if more than one person is delegated to complete the Encounter

Data Certification form.

Send this complete original Signature Authorization form to:

Christal Kelly, MBA

Associate Director of Provider Reimbursement

Division of Medical Assistance

333 E. Six Forks Road, Suite 200

Raleigh, NC 27609

Christal.Kelly@dhhs.nc.gov

NC Department of Health and Human Services

Division of Medical Assistance

July 7, 2017 v.2

Encounter Data Signature Authorization Form - Nc Department Of Health And Human Services