Effective Communications - FOR KELLY JACOBS

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AGENCY FOR HEALTH CARE ADMINISTRATION PROVIDER ENROLLMENT CORRESPONDENCE COVER SHEET

This sheet must be mailed or faxed with all documents.

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Name: ALPHA OMEGA ALLIANCE INC

Date Submitted: 20150915

Provider ID: 015016000

Mail To: P.O Box 7070 Tallahassee, FL 32314-7070

Attention: Mailroom Supervisor

Fax Number: (866) 270-1497

NOTE: The fax machine receiving the fax requires that the image setting be set to FINE or SUPERFINE. If you cannot change the image settings on the fax machine, and the images are not viewable, it will be necessary to mail a copy of the required documentation, along with the appropriate cover sheet, to the address on the Fax Coversheet.

Also, the fax coversheet that is produced by the Web Portal should be the first page of the fax transmission. Proprietary coversheets slow the process and should not be used. If you do not have access to the coversheet created by the Web Portal, please include a

coversheet that contains the nine-digit Medicaid Provider ID number.

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