We use cookies to improve security, personalize the user experience, enhance our marketing activities (including cooperating with our marketing partners) and for other business use.
Click "here" to read our Cookie Policy. By clicking "Accept" you agree to the use of cookies. Read less
Read more
Accept
Loading
Form preview
  • US Legal Forms
  • Form Library
  • More Forms
  • More Multi-State Forms
  • Fd-20b (revised 03012013) (2).doc 2020

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

How it works

  1. Open form

    Open form follow the instructions

  2. Easily sign form

    Easily sign the form with your finger

  3. Share form

    Send filled & signed form or save

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.

  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.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Get form

Related content

McGuire Nuclear Station, Units 1 and 2 - NRC
Mar 1, 2013 — Two specific pump relief requests, MC-SRP-KC-01 and ... FD, KD, VG and...
Learn more

Related links form

Waiver Of Liability Form Accident Release And Waiver Of Liability How To Join Daughters Of The Confederacy Dc100a

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
Get form
If you believe that this page should be taken down, please follow our DMCA take down processhere.

Industry-leading security and compliance

US Legal Forms protects your data by complying with industry-specific security standards.
  • In businnes since 1997
    25+ years providing professional legal documents.
  • Accredited business
    Guarantees that a business meets BBB accreditation standards in the US and Canada.
  • Secured by Braintree
    Validated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.
Get FD-20B (Revised 03012013) (2).doc
Get form
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232