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OF <br /> State of North Carolina <br /> Department of Human Resources <br /> Division of Medical Assistance <br /> 336 Fayetteville street Mall. <br /> Wake County Courthouse Annex <br /> Raleigh, North Carolina 27601 <br /> NORTH CAROLINA <br /> MEDICAL ASSISTANCE PROGRAM. <br /> (TITLE XIX - MEDICAID) <br /> LOCAL HEALTH DEPARTMENT <br /> or. <br /> DEVELOPMENTAL EVALUATION CENTER <br /> pARTICIPATION AGREEMENT <br /> Title XIX Provider Number <br /> Name O PrOv er <br /> Telephone i�um er <br /> ]. <br /> Street A ress C y � State Zxp <br /> By this. agreement the above-named provider and the North <br /> Carolina Division of Health Services (DAs) agree to participate: <br /> cooperatively in the provision of approved Medicaid services <br /> to eligible recipients of the north Carolina Medical. Assistance <br /> program" Title XIX approved services and reimbursement rates for <br /> this contract period are those lasted in Addenda A, B, C, and D. <br /> ' The pro'v'ider certifies that the clinic is operated to provide <br /> i <br /> s medical care in the form of physician supervised. clinical services <br /> i <br /> i 'which are diagnostic, therapeutic, rehabilitative and/or pallia- <br /> Live in nature. <br /> The provider certifies that patier& care is performed under <br /> F. <br /> Z <br /> 4 <br /> F <br /> t <br />