CCRI Enrollment Short Form - Westmoreland County 2025

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The document is a guide for completing the Consolidated Community Reporting Initiative (CCRI) Provider Enrollment Application Short Form in Pennsylvania. It is intended for providers already enrolled in Medical Assistance Fee-for-Service or HealthChoices who wish to enroll as CCRI providers. The application requires details such as effective enrollment date, provider ID, applicant's name, provider type and specialty, license number, service location, and contact information. Completed applications must be submitted to the appropriate county representative or via email.

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