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Get Fd-20b (revised 03012013) (2).doc 2020-2025
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How to use or fill out the FD-20B (Revised 03012013) (2).doc online
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.
- Click ‘Get Form’ button to obtain the FD-20B (Revised 03012013) (2).doc and open it in your editor.
- 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.
- Under the section for the NPI number, input your unique National Provider Identifier number. This is crucial for identification within the healthcare system.
- Fill in your date of birth in the designated field to confirm your identity.
- Enter your complete practitioner address including street, city, state, and zip code for correspondence purposes.
- Provide details for the contact person, including their name and phone number, as well as your email address for any follow-up communication.
- Input the type of service you provide and your Social Security number in the relevant fields for verification.
- Add your tax identification number and any applicable physician or non-physician specialty details.
- If applicable, indicate the earliest date that a service was provided to a Medicaid recipient.
- Now report any Medicare numbers, lab-CLIA numbers, or state licenses that pertain to your practice.
- Complete the section regarding any convictions, exclusions, revocations, or suspensions. Ensure you are truthful and thorough in this area.
- Sign and date the practitioner certification statement at the bottom of the form, confirming that your information is accurate.
- If someone else completed the form, that person also needs to sign and date the appropriate section.
- 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.
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