Masshealth npis form is a critical part of the application process for individuals who need health insurance. This form can be confusing, so it is important to understand the requirements and how to complete it accurately. The Masshealth npis form is used to determine eligibility for medical assistance in Massachusetts. In order to submit an accurate application, it is important to understand what information is required and how to provide it. The following guide will help you understand the requirements and complete the form correctly.
You will discover information regarding the type of form you need to fill out in the table. It will tell you how long it will require to complete masshealth npis form, what fields you need to fill in, and so forth.
| Question | Answer |
|---|---|
| Form Name | Masshealth Npis Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Simplification, NPI, CFR, Portability |
Commonwealth of Massachusetts
EOHHS
www.mass.gov/masshealth
MassHealth Provider Application National
Provider Identifier (NPI) Supplement
For Internal use only
MassHealth provider number:
MassHealth provider type:
This supplement to this application is for the collection of national provider identifier (NPI) data. The NPI number is required for all
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
City
State
Zip
Tax ID
NPI number
Check if not eligible for NPI Number
Is this NPI associated with another MassHealth Provider ID you currently have on file?. . . . . . . . . yes |
no |
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If YES, please indicate the other provider ID(s): |
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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 applicant: |
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Date: |
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Email: |
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Phone: |
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Printed legal name of individual signing:
(if the applicant is a legal entity)
NPIS (Rev. 09/10)