National Provider Identifier Npi Application Update Form Details

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QuestionAnswer
Form NameForm Cms 10114 Ef
Form Length3 pages
Fillable?Yes
Fillable fields96
Avg. time to fill out20 min 1 sec
Other namesnpi application online, application form for npi number, npi address change form, national provider identifier npi application update form

Form Preview Example

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved OMB No. 0938-0931

NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM

Please PRINT or TYPE all information so it is legible. Do not use pencil. Failure to

provide

complete

and accurate information may cause your application to be returned and delay processing of your

 

application. In addition, you may experience problems being recognized by insurers

if the

records in

their systems do not match the information you have furnished on this form.

 

 

SECTION 1 - BASIC INFORMATION

A. Reason For Submittal Of This Form

(Check the appropriate box)

1.

Initial Application

 

 

3. Deactivation

NPI No.

 

 

2.

Change of Information

(See Instructions)

REASON (Check one of the following)

 

 

 

 

 

 

NPI No.

 

 

 

Death

Business Dissolved

B. Entity Type

 

 

 

Other:

 

 

 

(Check the appropriate box)

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

2.

An individual who renders health care. An organization that renders health care.

(Complete Sections 2A, 3, 4A, and 5) (Complete Sections 2B, 3, 4B and 5)

SECTION 2 - IDENTIFYING INFORMATION

A. Individuals

1. Prefix (e.g.,Major, Mrs.)

 

2. First

 

 

 

3. Middle

 

 

 

4. Last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Suffix (e.g., Jr., Sr.)

 

 

 

 

 

 

6. Credential (e.g., M.D., D.O.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Name Information (If applicable. Use additional sheets of paper if necessary)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Prefix (e.g.,Major, Mrs.)

 

8. First

 

 

 

9. Middle

 

 

10. Last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. Suffix (e.g., Jr., Sr.)

 

 

 

 

 

 

12. Credential (e.g., M.D., D.O.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Type of other Name

Professional Name

 

 

 

 

 

 

 

 

 

Former Name

Other

(Describe)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. Date of Birth (mm/dd/yyyy)

 

 

15. State of Birth (U.S. only)

 

 

 

16. Country of Birth (If other than U.S.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17. Gender

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. Social Security Number (SSN)

 

 

 

19. IRS Individual Taxpayer Identification Number

 

 

 

 

 

 

 

 

 

 

 

 

B. Organizations and Groups

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Name (Legal Business Name)

 

 

 

 

2. Employer Identification Number (EIN) or SSN

 

 

 

 

 

 

 

 

 

 

 

3. Other Name (Use additional sheets of paper if necessary)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Type of Other Name

 

 

 

 

 

 

 

 

 

 

 

 

Former Legal Business Name

D/B/A Name

Other

(Describe)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form CMS-10114 (02/05) EF (05/2005)

1

SECTION 3 - ADDRESSES AND OTHER INFORMATION

A. Mailing Address Information

1.Mailing Address Line 1 (Street Number and Name or P.O. Box)

2. Mailing Address Line 2 (Address Information; e.g., Suite Number)

3.City

4. State

5. ZIP+4 or Foreign Postal Code

6. Country Name (if outside U.S.)

7. Telephone Number (Include Area Code & Extension)

8.Fax Number (Include Area Code)

B. Practice Location Information

1. Primary Practice Location Address Line 1

(Street Number and Name - P.O. Boxes Not Acceptable)

2.Primary Practice Location Address Line 2 (Address Information; e.g., Suite Number)

3. City

 

4. State

5. ZIP+4 or Foreign Postal Code

 

 

 

 

6. Country Name

(if outside U.S.)

 

7.Telephone Number (Include Area Code & Extension)

8.Fax Number (Include Area Code)

C. Other Provider Identification Numbers

(Use additional sheets of paper if necessary)

 

 

 

 

 

Number Type

Number

State (if applicable)

Issuer (Other type)

UPIN

Medicare

Medicaid

Other

Other

D. Provider Taxonomy Code

(Provider Type/Specialty. Enter one or more codes)

and License Number Information

Information on provider taxonomy codes is available at www.wpc-edi.com/taxonomy. Please see instructions if you plan to submit more than one taxonomy code for a Type 2 (organization) entity.

1. Primary Provider Taxonomy Code or describe your specialty or provider type (e.g., chiropractor , pediatric hospital)

2. License Number

3. State where issued

 

 

4. Provider Taxonomy Code or describe your specialty or provider type (e.g., chiropractor, pediatric hospital)

5. License Number

6. State where issued

 

 

7. Provider Taxonomy Code or describe your specialty or provider type (e.g., chiropractor, pediatric hospital)

8. License Number

9. State where issued

 

 

Form CMS-10114 (02/05) EF (05/2005)

2

PENALTIES FOR FALSIFYING INFORMATION ON THE

NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM

18 U.S.C. 1001 authorizes criminal penalties against an individual who in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick,

scheme or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or

entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to 5 years. Offenders that

are organizations are subject to fines of up to $500,000. 18 U.S.C. 3571(d) also authorizes fines of up to twice the gross gain derived by the offender if it is greater than the amount specifically authorized by the sentencing statute.

SECTION 4 - CERTIFICATION STATEMENT

I, the undersigned, certify to the following:

This form is being completed by, or on behalf of, a health care provider as defined at 45 CFR 160.103.

I have read the contents of the application and the information contained herein is true, correct and complete. If I

become aware that any information in this application is not true, correct, or complete, I agree to notify the NPI Enumerator of this fact immediately.

I authorize the NPI Enumerator to verify the information contained herein. I agree to notify the NPI Enumerator of any changes in this form within 30 days of the effective date of the change.

I have read and understand the Penalties for Falsifying Information on the NPI Application/Update Form as printed in this application. I am aware that falsifying information will result in fines and/or imprisonment.

A. Individual Practitioner's Signature

1. Applicant's Signature (First, Middle, Last, Jr., Sr., M.D., D.O., etc.)

2. Date (mm/dd/yyyy)

 

 

B. Authorized Official's Information and Signature for the Organization

1.

Prefix (e.g.,Major, Mrs.)

2. First

3.

Middle

4. Last

 

 

 

 

 

 

5.

Suffix (e.g., Jr., Sr.)

 

6.

Credential (e.g., M.D., D.O.)

 

 

 

 

 

 

7. Title/Position

 

 

 

8. Telephone Number (Area Code & Extension)

 

 

 

 

 

 

9.

Authorized Official's Signature (First, Middle, Last, Jr., Sr., M.D., D.O., etc.)

 

 

10. Date (mm/dd/yyyy)

 

 

 

 

 

 

SECTION 5 - CONTACT PERSON

A. Contact Person's Information

 

Check here if

you are

the same person

identified in 2A

or 4B.

 

If you checked the box, complete only item 8, e-mail address in this section (Section 5).

 

 

 

 

 

 

 

 

 

1.

Prefix (e.g.,Major, Mrs.)

 

2. First

 

3.

Middle

4. Last

 

 

 

 

 

 

 

 

 

5.

Suffix (e.g., Jr., Sr.)

 

 

 

6.

Credential (e.g., M.D., D.O.)

 

 

 

 

 

 

 

 

 

7. Title/Position

 

 

 

8. E-Mail Address

 

9. Telephone Number

 

 

 

 

 

 

 

 

 

For the most efficient and fast receipt of your NPI, please use the web-based NPI process at the following address: https://nppes.cms.hhs.gov.NPI web is a quick and easy way for you to get your NPI.

Or send the completed application to: NPI Enumerator

P.O. Box 6059

Fargo, ND 58108-6059

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0931. The time required to complete this information collection is estimated to average 20 minutes per response for new applications and 10 minutes for changes, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, Attn: Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Do not send the applications to this address.

Form CMS-10114 (02/05) EF (05/2005)

3

How to Edit Form Cms 10114 Ef

It is simple to obtain documents using our PDF editor. Modifying the npi change form document is straightforward in the event you keep up with the next steps:

Step 1: Select the button "Get form here" to get into it.

Step 2: You will find all the actions that you can take on your document once you've got entered the npi change form editing page.

You should type in the following details to complete the npi change form PDF:

writing npi application update form stage 1

In the Former Name, Professional Name, Other, (Describe), Female, Former Legal Business Name, D/B/A Name, Other, (Describe), and Form CMS-10114 (02/05) EF (05/2005) field, put down your data.

part 2 to completing npi application update form

The program will require for more information as a way to effortlessly fill in the area (Address Information; e, (Include Area Code & Extension), and (Street Number and Name - P.

npi application update form (Address Information; e, (Include Area Code & Extension), and (Street Number and Name - P blanks to fill

Feel free to list the rights and responsibilities of the sides within the (Use additional sheets of paper if, Number, State (if applicable), Issuer (Other type), Number Type, UPIN, Medicare, Medicaid, Other, Other, (Provider Type/Specialty, and License Number Information, and Information on provider taxonomy box.

npi application update form (Use additional sheets of paper if, Number, State (if applicable), Issuer (Other type), Number Type, UPIN, Medicare, Medicaid, Other, Other, (Provider Type/Specialty, and License Number Information, and Information on provider taxonomy fields to fill out

End up by reading the next areas and filling them out correspondingly: Form CMS-10114 (02/05) EF (05/2005).

npi application update form Form CMS-10114 (02/05) EF (05/2005) blanks to fill out

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