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ALAMEDA COUNTY HEALTH CARE SERVICES AGENCY
SB 12 PHYSICIAN REIMBURSEMENT PROGRAM
Full legal name of entity
DBA to be used for SB 12 billing
Type of Entity: □ Individual □
Tax ID Number (TIN) __________________________________
Composition of ownership. This is a Mandatory
LOC □ Local Vendor (Has street address and holds business license within Alameda County)
SML □ Small Business (as defined by Small Business Administration)
FEM □ Female (>50%)
AFA □ Black or African American (>50%)
ASN □ Asian (>50%)
NAT □ Native Hawaiian or other Pacific Islander (>50%)
AIN □ American Indian or Alaskan Native (>50%)
The collection of ethnicity and gender data is for statistical and demographical purposes only.
Correspondence Address
Remittance Address, if different
Billing Service Name
Contact Name
Contact Phone Number
Hospital/Group/Affiliation
ALAMEDA COUNTY HEALTH CARE SERVICES AGENCY
Public Health Department – Administrative Services
Finance-Contracts and Grant Claiming
SB 12 PHYSICIAN REIMBURSEMENT PROGRAM
PROVIDER ENROLLMENT
(Please print or type)
Sole Proprietor □ Partnership □
Tax ID Number (TIN) _____________________________________________________ □ SSN
Composition of ownership. This is a Mandatory Section. Please check all that apply.
Local Vendor (Has street address and holds business license within Alameda County)
Small Business (as defined by Small Business Administration)
MLE □ Male (>50%)
50%) WHIT □ White (>50%)
HIS □ Hispanic or Latino (>50%)
Native Hawaiian or other Pacific Islander (>50%) FIL □ Filipino (>50%)
American Indian or Alaskan Native (>50%) POE □ Publicly Owned
The collection of ethnicity and gender data is for statistical and demographical purposes only.
Contact E-mail Address
Contact FAX Number
SB 12 PHYSICIAN REIMBURSEMENT PROGRAM
Medical Corporation
SSN □ EIN
Hispanic or Latino (>50%)
Filipino (>50%)
Publicly Owned Entity