Get Disclosure Form For A Provider Person I ... - Tn.gov - Tn

Completing the disclosure form for a provider person is essential for obtaining a TennCare/Medicaid provider ID number. This guide aims to provide clear and straightforward instructions to help you successfully navigate each section of the form.

Follow the steps to fill out the disclosure form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document management tool.
2. Begin by providing identifying information. Fill in your National Provider Identifier (NPI) number, name, home address, Social Security Number (SSN), date of birth (DOB), city, state, and zip code. Include your TennCare/Medicaid ID number if applicable.
3. Complete the section for the provider entity. Provide the name, Tax Identification Number (T.I.N.), address, and any 'doing business as' (DBA) names for the entity that employs you.
4. In the criminal offense attestation section, answer specific questions regarding any convictions or exclusions from federal programs. Be truthful and comprehensive—if necessary, provide additional details on a separate sheet.
5. For sole proprietors, provide information for managing employees and agents, including their names, SSNs, and addresses. Answer related questions regarding their criminal history as directed.
6. After completing all sections, review your responses to ensure accuracy. If a question is not applicable, write 'N/A' instead of leaving it blank. Ensure that no questions are omitted.
7. Sign and date the form in the designated section. Remember, signatures must be handwritten, and printed names must be clearly legible.
8. Finally, save your completed form, and proceed to download, print, or share it as needed. Make sure to retain a copy for your records before submitting it to the address indicated.

Complete your documents online today to ensure your application process is seamless and efficient.