Masshealth Npis Form PDF Details

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.

QuestionAnswer
Form NameMasshealth Npis Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesSimplification, NPI, CFR, Portability

Form Preview Example

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 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

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

If YES, please indicate the other provider ID(s):

 

 

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:

 

 

 

Date:

 

 

 

 

 

 

 

 

 

Email:

 

 

Phone:

 

 

 

 

Printed legal name of individual signing:

(if the applicant is a legal entity)

NPIS (Rev. 09/10)

Watch Masshealth Npis Form Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .