DMHAS Fee-For-Service Network
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DMHAS Fee-For-Service Network Contract Enrollment Application FY 2013-14
AGENCY ADMINISTRATIVE INFORMATION CONTRACT APPLICATION SIGNATURE PAGE
AGENCY NAME:
ADMINISTRATIVE ADDRESS:
CITY: STATE: ZIP: -
COUNTY:
TELEPHONE NUMBER: ( ) ext
FAX NUMBER: ( ) ext
FEDERAL TAX ID #: (Will be confirmed upon submission of required contract application documents)
ADMINISTRATIVE CONTACT:
NAME:
TITLE:
EMAIL ADDRESS:
SIGN NAME:
PRINT NAME:
TITLE:
DATE:
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DMHAS FFS Enrollment materials are due by October 1st 5:00 pm Fall 2012 enrollment
DMHAS Fee-For-Service Network Contract Enrollment Application FY 2013-14 Mailing Information for submission of Contract Enrollment Application:
Overnight: New Jersey Division of Mental Health & Addiction Services 222 South Warren Street- 3rd floor Trenton, NJ 08611 Attention: Geralyn Molinari
Postal delivery: New Jersey Division of Mental Health & Addiction Services P.O. Box 362 Trenton, NJ 08625-0362 Attention: Geralyn Molinari
Page 2 of 2
DMHAS FFS Enrollment materials are due by October 1st 5:00 pm Fall 2012 enrollment