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Federally required disclosures form

Pe frd in 2025

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The document outlines the federally required disclosures for individual practitioners seeking to provide services to MassHealth members in Massachusetts. It details the necessary information that must be submitted, including personal identification, service location, relationships with other entities, and any relevant legal or disciplinary history. The form emphasizes compliance with federal regulations and mandates accurate reporting under penalty of perjury.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (254 Votes)

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