Get Indiana Ihcp Provider Recertification Form 2016-2025
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How to fill out the Indiana IHCP Provider Recertification Form online
Filling out the Indiana IHCP Provider Recertification Form online is a crucial step for enrolled providers to ensure their licenses and certifications are updated. This guide offers a detailed, step-by-step approach to help you navigate the process smoothly and effectively.
Follow the steps to complete the recertification form online.
- Click ‘Get Form’ button to obtain the Indiana IHCP Provider Recertification Form in the editor.
- Fill out the provider legal name in Field 1, ensuring accurate spelling and format.
- In Field 2, enter your Legacy Provider Identifier (LPI) and service location alpha suffix as required.
- Input your National Provider Identifier (NPI) in Field 3 to maintain consistent identification.
- Complete Field 4 with your taxonomy to specify your provider type.
- Provide the ZIP + 4 code in Field 5 for accurate geographical identification.
- In Field 6, enter your Taxpayer Identification Number (TIN) for tax purposes.
- For group or clinic providers, complete the rendering provider information in Fields 7-9.
- Common carrier transportation providers should include their specific numbers in Fields 10 and 11.
- Fill out the contact person's information in Fields 12-14 for efficient communication about the form.
- Complete the authorized signature information in Fields 15-18, ensuring the signature is original to prevent return of the form.
- After completing all fields, perform a quality check to confirm all necessary information and documentation is provided.
- Make a copy of the completed form and supporting documents for your records.
- Submit the form and all required documents to the Hewlett Packard Enterprise Provider Enrollment Unit at the provided address.
Ensure your licenses and certifications are updated—complete the Indiana IHCP Provider Recertification Form online today.
The fax number for Medicaid in Indiana varies depending on the department or service you are trying to reach. It's recommended to check the official Indiana Medicaid website for the most accurate and current fax numbers. Having the right contact details is crucial for timely communication. For any related forms, including the Indiana IHCP Provider Recertification Form, uslegalforms can provide valuable assistance.
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