American Osteopathic Association / PAYMENT INCREASE SELF-ATTESTATION DEPARTMENT OF HUMAN SERVICES / Medicare / Family Practice Board of Certification / /
Person
CINDY SHELDON / / /
Position
ACA physician / physician / Physician Information First Name Middle Initial Practice Name NPI Number ND Medicaid Provider ID Number / eligible physician / General / supervising physician / OR The physician / qualifying physician / /
PRIMARY CARE ENHANCED PAYMENT INCREASE SELF-ATTESTATION DEPARTMENT OF HUMAN SERVICES - MEDICAL SERVICES DIVISION Complete, sign, and mail all documentation to: ND DHS MEDICAL SERVICES ATTN: CINDY SHELDON