Get Institutionalrate Based Emedny Enrollment Form

Filling out the Institutionalrate Based Emedny Enrollment Form online can be simplified with a clear understanding of its components. This guide aims to provide you with detailed, step-by-step instructions to complete the form accurately and efficiently.

Follow the steps to complete the enrollment form successfully.

1. Press the ‘Get Form’ button to access the Institutionalrate Based Emedny Enrollment Form and open it in your preferred editing tool.
2. Fill in the application date and federal employer identification number (FEIN) in the designated fields. Remember to attach a copy of your FEIN letter as a W-9 form is insufficient.
3. Specify the provider name and any 'doing business as' (DBA) name if applicable. If your facility uses an assumed name, ensure to enter that here.
4. Provide your national provider identifier (NPI) and attach a copy of the NPI verification email. If this facility operates under multiple NPIs, submit a separate enrollment application for each.
5. Indicate the major taxonomy codes associated with your NPI, placing more codes on an additional sheet if necessary.
6. Fill out the license or operating certificate number(s) for relevant agency codes, along with their begin and expiration dates.
7. Select the appropriate ownership code and control of facility code from the provided listings to reflect your entity type.
8. Complete sections regarding Medicare participation, number of Medicare and Medicaid beds, and attach the necessary documentation as specified in the form.
9. Enter the mandatory address information for correspondence, pay-to, service, and corporate address sections with accurate details and proper abbreviations.
10. Respond to the compliance and ownership questions carefully, providing truthful information and attaching any additional documentation if required.
11. Sign and date the form, ensuring that the authorized representative's name and their title are correctly printed.
12. Finally, review all entries for accuracy. Save changes, and you may choose to download, print, or share the completed form as needed.

Complete your Institutionalrate Based Emedny Enrollment Form online to ensure a smooth enrollment process.