Get Fd-20b (revised 03012013) (2).doc 2020-2025

Filling out the FD-20B form online can seem overwhelming, but with clear guidance, it can be a straightforward process. This guide offers step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the FD-20B form online.

1. Click ‘Get Form’ button to obtain the FD-20B (Revised 03012013) (2).doc and open it in your editor.
2. Begin by providing the practitioner name at the top of the form. Ensure you enter your full name as it appears in your professional records.
3. Under the section for the NPI number, input your unique National Provider Identifier number. This is crucial for identification within the healthcare system.
4. Fill in your date of birth in the designated field to confirm your identity.
5. Enter your complete practitioner address including street, city, state, and zip code for correspondence purposes.
6. Provide details for the contact person, including their name and phone number, as well as your email address for any follow-up communication.
7. Input the type of service you provide and your Social Security number in the relevant fields for verification.
8. Add your tax identification number and any applicable physician or non-physician specialty details.
9. If applicable, indicate the earliest date that a service was provided to a Medicaid recipient.
10. Now report any Medicare numbers, lab-CLIA numbers, or state licenses that pertain to your practice.
11. Complete the section regarding any convictions, exclusions, revocations, or suspensions. Ensure you are truthful and thorough in this area.
12. Sign and date the practitioner certification statement at the bottom of the form, confirming that your information is accurate.
13. If someone else completed the form, that person also needs to sign and date the appropriate section.
14. Finally, review the entire document for completeness and accuracy. Save changes, and download the form as needed. You can print it for submission or share it electronically.

Complete your FD-20B form online today to ensure your application is processed smoothly.