PACE PROVIDER RE-ENROLLMENT
April 6, 2007
As stated in the instructions, providers must include the PHARMACY NAME in the space provided in the first paragraph of the Agreement.
National Provider Identifier No.: _1234567899_ N.C.P.D.P. No.: __3912345_ PACE/PACENET Provider No.: 0391234_
PROVIDER AGREEMENT FOR
PENNSYLVANIA PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY AND
THE PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY NEEDS ENHANCEMENT TIER
This Agreement made by and between the Pennsylvania Department of Aging, Pharmaceutical Assistance Contract for the Elderly (hereinafter “PACE”), and the Pharmaceutical Assistance Contract for the Elderly Needs Enhancement Tier (hereinafter “PACENET”) or its Authorized Agent (hereinafter the “Program”) and ___________________________ (hereinafter the “Provider”) sets forth the terms and conditions governing participation in PACE and PACENET. PACE, PACENET and The Provider are also sometimes referred to as the “Parties.” The Parties agree that the term “Program” includes both the PACE and PACENET Programs. The Parties, intending to be legally bound, agree as follows:
I. PROVIDER RESPONSIBILITIES
The Provider agrees to participate in the PACE and PACENET Programs and in the course of such participation to comply with all Federal and Pennsylvania laws generally and specifically governing participation in the PACE and PACENET Programs. The Prov-
Agreements missing this name will be returned unprocessed.
To date, 25% of the received re-enrollments have been returned for
Please review your documents carefully to insure all information is completed and correct.
Questions may be directed to Provider Services at