Get New Location Code Request - Agingflorida.net

This guide provides clear and detailed instructions for filling out the New Location Code Request form for AgingFlorida.net online. It is designed to assist users through each section of the form, ensuring accuracy and completeness.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the provider name in the designated field, ensuring it matches your registered name.
3. Fill in the base provider number, which consists of seven digits followed by a two-digit suffix.
4. Input the new location’s provider type code by entering the first seven digits of your Medicaid ID.
5. Provide the new location’s specialty code. Refer to the guide or contact the fiscal agent for available codes.
6. Enter the new location’s license number. If you are a home health agency branch or PPEC provider, attach a copy of the license.
7. Fill out the service address details, including building or suite number, city, state, and ZIP code.
8. Provide the business location telephone and fax numbers, including area codes.
9. Indicate the county where the new location is situated.
10. For the pay-to address and correspondence address, fill in the necessary details, or leave it blank if it defaults to the service address.
11. Complete the home/corporate office address if different from the service address.
12. Ensure the form is signed and dated by the provider or an authorized agent.
13. Review all entries for accuracy before finalizing.
14. Finally, save the changes, download, print, or share the form as needed.

Complete your New Location Code Request online today to ensure your services are billed correctly.