Durham LRC Provider Enrollment Form

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Please correct the field(s) marked in red below:

Provider Information Form
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Provider Information Form
Address
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Address
Brief Agency Description
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Brief Agency Description
Please indicate the services provided by your organization.  Check ALL that apply. 
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Please indicate the services provided by your organization. Check ALL that apply.
Does your agency charge a fee for services?
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Does your agency charge a fee for services?
If you answer yes to the above question, what is the fee amount?
Are there eligibility restrictions for the services your agency provides?
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Are there eligibility restrictions for the services your agency provides?
If Yes, List restrictions
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