5402. REQUIRED INFORMATION

5402 REQUIRED INFORMATION 5402.1 Each fee-for-service primary care provider shall submit the address of each site at which services will be provided to AFDC and AFDC-related recipients to the Department at the time of filing an application for a Medicaid managed care provider agreement. 5402.2 Each fee-for-service primary care provider that is a clinic, hospital outpatient hospital department or group practice shall submit to the Department at the time of filing an application for a Medicaid managed care provider agreement the name and documentation supporting the qualifications of all primary care physicians that will be rendering service to AFDC and AFDC-related recipients, in a format specified by the Department. 5402.3 Each fee-for-service primary care provider shall notify the Department in writing of any material change in the information required in §5402.1 and 5402.2 within thirty (30) days of the date of the change. SOURCE: Final Rulemaking published at 42 DCR 1566, 1589 (March 31, 1995).