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<br /> <br /> Page 20 of 48 <br />PARTICIPATING PROVIDER AGREEMENT <br /> <br />SCHEDULE C <br />INFORMATION FOR CONTRACTED PROVIDERS <br /> <br />Provider shall provide WellCare with the information set forth below with respect to: (i) Provider; (ii) each Contracted <br />Provider; and (iii) if applicable, each Contracted Provider’s locations and/or professionals. To the extent Provider <br />provides the name of any Contracted Provider to WellCare hereunder, such entity and/or individual will be considered <br />a Contracted Provider under this Agreement regardless of whether the complete list of information set forth below <br />relating to such Contracted Provider is provided by Provider. <br /> <br />1. Name <br />2. Address <br />3. E-mail address <br />4. Telephone and facsimile numbers <br />5. Professional license numbers <br />6. Medicare/Medicaid ID numbers <br />7. Federal tax ID numbers <br />8. Completed W-9 form <br />9. National Provider Identifier (NPI) numbers <br />10. Provider Taxonomy Codes <br />11. Area of medical specialty <br />12. Age restrictions (if any) <br />13. Area hospitals with admitting privileges (where applicable) <br />14. Whether Providers are employed or subcontracted with Contracted Provider using the designation “E” for <br />employed or “C” for subcontracted. <br />15. For a subcontracted Provider, whether its Providers are employed or contracted with the subcontracted Provider <br />using the designation “E” for employed or “C” for contracted. <br />16. Office contact person <br />17. Office hours <br />18. Billing office <br />19. Billing office address <br />20. Billing office telephone and facsimile numbers <br />21. Billing office e-mail address <br />22. Billing office contact person <br />23. Ownership Disclosure Form, as required to comply with Laws, Program Requirements, and Government <br />Contract <br /> <br />NOTE: For a complete listing of the information and additional documentation required, please refer to the <br />enrollment application <br /> <br /> <br />DocuSign Envelope ID: 2EC1F0FD-FAF9-4B42-B52E-D419F55A6210