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) |
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B. Authorized Official's Information and Signature for the Organization
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Prefix (e.g.,Major, Mrs.) |
2. First |
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Middle |
4. Last |
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5. |
Suffix (e.g., Jr., Sr.) |
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6. |
Credential (e.g., M.D., D.O.) |
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7. Title/Position |
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8. Telephone Number (Area Code & Extension) |
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Authorized Official's Signature (First, Middle, Last, Jr., Sr., M.D., D.O., etc.) |
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10. Date (mm/dd/yyyy) |
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SECTION 5 - CONTACT PERSON
A. Contact Person's Information
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Check here if |
you are |
the same person |
identified in 2A |
or 4B. |
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If you checked the box, complete only item 8, e-mail address in this section (Section 5). |
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1. |
Prefix (e.g.,Major, Mrs.) |
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2. First |
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Middle |
4. Last |
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5. |
Suffix (e.g., Jr., Sr.) |
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6. |
Credential (e.g., M.D., D.O.) |
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7. Title/Position |
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8. E-Mail Address |
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9. Telephone Number |
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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.