Get Npi Deactivation Form

Filling out the NPI Deactivation Form online is a crucial step in maintaining the integrity of provider information. This guide will walk you through each section of the form, ensuring a smooth and accurate submission process.

Follow the steps to successfully complete the NPI Deactivation Form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by selecting one of the options provided for either adding, modifying, or deleting NPIs. This is crucial to indicate your intent with the NPIs that your domain needs access to.
3. In the 'Provider/Facility Name' field, enter the name of the relevant provider or facility associated with the NPI.
4. Next, fill in the 'NPI' field with the specific number associated with the provider or facility.
5. If there are additional NPIs required beyond what is provided in the main form, utilize 'Attachment C(a)' as instructed. Ensure that this additional list is organized correctly.
6. Complete the 'Name of Provider/Plan' section by entering the name of the provider or plan for clarity.
7. Fill out the 'Name of PEDI Liaison,' 'Liaison Phone,' 'Title,' 'Liaison FAX,' and 'Liaison E-Mail Address' sections to provide contact details for communication.
8. Please include the 'Street Address,' 'City,' 'State,' and 'Zip' to specify the address for the liaison.
9. Once all sections are filled out accurately, review the information for completeness.
10. Finally, save your changes, and choose to either download, print, or share the completed form as needed.

Complete the NPI Deactivation Form online today to ensure up-to-date provider information!