Masshealth Npis Form – Fill Out and Use This PDF

This supplement to this application is for the collection of national provider identifier (NPI) data. The NPI number is required for all health-care providers under the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA). In addition, federal regulations at 42 CFR 431.107(b)(5) require that all providers eligible for an NPI number furnish it to MassHealth and include it on all claims. If you are eligible for an NPI number, failure to provide it may result in a delay in processing your application.

Please list your name, address, Tax ID, and NPI number applicable to this enrollment.

SECTION 11. NATIONAL PROVIDER IDENTIFIER

Provider’s legal name

Street address line 1

Street address line 2

APPLICANT’S ATTESTATION, SIGNATURE, AND DATE

I certify under the pains and penalties of perjury that the information on this form has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I also certify that I am the applicant or, in the case of a legal entity, duly authorized to act on behalf of the applicant. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.

Applicant’s signature:

(Signature and date stamps, or the signature of anyone other than the applicant or person legally authorized to sign on behalf of a legal entity, are not acceptable).

Printed legal name of individual signing:

(if the applicant is a legal entity)

NPIS (Rev. 09/10)

Clear entire form.