Get Update Physical - Mailing - W9 Address For The Pay-to Record

Completing the Update Physical - Mailing - W9 Address For The Pay-To Record is essential for maintaining accurate details in the Idaho Medicaid system. This guide provides clear, step-by-step instructions to ensure all necessary information is submitted correctly.

Follow the steps to accurately complete your form.

1. Click ‘Get Form’ button to access the form and open it in your PDF editor.
2. Fill in the 'Current Provider and Contact Information' section. Include the Pay-To name of your organization or individual, National Provider Identifier (NPI), and Tax ID (FEIN or SSN). Also, provide a contact name, phone number, and email address for any inquiries related to your information.
3. Complete the 'Pay-To Address / W9 Information' section. Enter the physical address where services are provided and the correspondence mailing address where all communication is sent. Ensure the W-9 information matches the details on your W-9 form. Provide the type of tax entity as well.
4. In the 'Pay-To Physical Address' section, indicate the effective date for the address change, group or clinic name, full address including city, state, and zip code.
5. Repeat the same process for the 'Pay-To Correspondence Mailing Address' section, ensuring all fields are appropriately filled out with accurate details.
6. For the 'Pay-To W-9 Information,' if the information is being updated, attach a new W-9 form found at the provided website. Fill out the effective date and W-9 name along with any other required fields.
7. Complete the 'Provider Statement' section. Print your name, title, and add your signature along with the date to verify the information is true and correct.
8. After completing the form, save your changes in the editor. You may then print the packet for your records.
9. Finally, mail, fax, or email the completed packet along with any required documentation to Molina Medicaid Solutions using the contact information provided in the instructions.

Begin filling out your form online today to ensure your information is up-to-date.