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Signature: Name (print or type): Signature Date: Authorized Signer Phone: Providers with multiple locations under one TIN will receive only one email. For multiple contacts, attach a separate sheet that indicates the practice location, TIN, NPI, email address, contact name, and phone number. You cannot change your mailing address with this form. You must use a Network Provider Change Form to change your mailing address. Primary Location/Designated Email for Newsletter/Correspondence Contact: P.

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How to fill out the Sivokgov Form online

Filling out the Sivokgov Form online is a straightforward process that can be completed in a few easy steps. This guide will help you navigate each section of the form, ensuring that you provide the necessary information accurately.

Follow the steps to complete the Sivokgov Form online.

  1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
  2. Enter the provider name in the designated field. This should be the official name of your organization as recognized by the relevant authorities.
  3. Input the Tax ID Number in the specified area. Ensure this number is accurate, as it is crucial for identification and tax purposes.
  4. Fill in the NPI (National Provider Identifier) in the NPI field. This unique identifier is essential for healthcare providers.
  5. Provide the authorized signature by printing or typing the authorized individual’s name. This person must have the authority to affirm the information on the form.
  6. Enter the date of signature to confirm when the document was signed.
  7. Fill in the authorized signer’s phone number to enable communication regarding the form.
  8. Designate the primary location contact by filling in their name, phone number, and email address. This is the main contact for correspondence.
  9. For additional locations, repeat the previous step by filling in the necessary contact details for each location up to four locations.
  10. After completing the form, review all entered information for accuracy. Ensure that all required fields are filled out correctly.
  11. Once verified, save your changes, and if needed, download or print the completed form for your records.
  12. Finally, return the completed form to the specified address or via the provided contact methods to ensure your updates are processed.

Take action now and complete your Sivokgov Form online to ensure your information is up to date.

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