EVV SERVICE PROVIDER EVV SERVICE PROVIDER Charter member Level 2 Level 1

MCO/HEALTH PLAN - PAYOR MCO/HEALTH PLAN - PAYOR Charter member Per Health or Community Plan

PROVIDER (AGENCY OR INDEPENDENT) PROVIDER (AGENCY OR INDEPENDENT) Charter Member Level 3 Level 2 Level 1

FEDERAL, STATE, OR ASSOCIATION (EMPLOYEE OR GROUP) FEDERAL, STATE, OR ASSOCIATION (EMPLOYEE OR GROUP) FEDERAL, STATE, OR ASSOCIATION (EMPLOYEE OR GROUP)

Organization/Company/Individual Name

Name of Primary Contact

Title

Address

City

State

Zip

Phone

Fax

Email

Company Website

OTHER INDIVIDUALS TO RECEIVE ASSOCIATION MAILINGS OR ELECTRONIC COMMUNICATIONS:

Name

Title

Address ( if different than above)

Phone

FAX

Email

Brief Description about the Member - Provider Type or State/Federal or Local Entity

How did you hear about NEVVA

Form completed by

date