NPA Signing

New agreement

Agreement date

Exhibit A — authorized facilities

Each facility you list here is authorized for submission. “Authorization Expires” auto-fills to the Authorization Date + 90 days; override it only if you mean a different window.

+ Add facility

Your signature (Provider)

You pre-sign here. Your signature goes on the §10 Provider line; your initials go on the Exhibit A “Provider Initials” and every page footer. The recruiter receives the agreement already signed by you and counter-signs it.

Signature — Adam Powell, CRNA Initials Remember my signature & initials on this device (so I don’t redraw them each time)

Agreement status

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