Get Jan 2016 Empire Participation Form

The Jan 2016 Empire Participation Form is essential for registering your National Provider Identification (NPI) with Empire. Completing this form accurately is crucial to ensure timely claim payments and uninterrupted operations.

Follow the steps to fill out the form accurately and effectively.

1. Click the ‘Get Form’ button to acquire the form and open it for editing.
2. Begin by entering your provider name in the dedicated field marked with an asterisk (*), as this is required information.
3. Input your NPI number, which is also marked as required.
4. Select your NPI entity type code, either 1 or 2, based on your provider status.
5. Provide your Social Security number, if applicable, or leave it blank if not required.
6. Enter your Tax ID number in the relevant section.
7. If you have an Employer ID number, fill it in accordingly.
8. Add your Empire Provider ID Number (EPIN) if you have one.
9. If relevant, include your DEA number.
10. Fill in your Medicare ID if you are registered under Medicare.
11. If applicable, include your Medicaid ID.
12. For pharmacies, input your NCPDP Number.
13. Indicate the license state where you practice.
14. Enter your license number for verification.
15. If you are part of a group practice, provide the group practice name.
16. Complete the location address, including city, state, and zip code, with the zip code being a required field.
17. Input your office phone number in the specified field.
18. Finally, fill in the taxonomy code to describe your provider specialty.
19. Add your contact name and title, both of which are marked as required.
20. Include a telephone number where you can be reached.
21. Review all entries carefully to ensure accuracy, then save your changes, and choose to download, print, or share the form as needed.

Complete your Jan 2016 Empire Participation Form online today to ensure a smooth registration process.