Get Credit Cardfor Credit Card Payments

Completing the Credit Card for Credit Card Payments form online is a straightforward process that ensures secure transactions. This guide provides clear instructions on how to effectively fill out each section of the form to facilitate your payments.

Follow the steps to successfully complete the form.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering your legal name in the designated field. This should match the name associated with your Tax ID as defined by the IRS.
3. Next, fill in the billing provider name, which is the name of the group or facility submitting the claim.
4. Indicate whether your practice is filing claims as a group or an individual by selecting the appropriate option.
5. Provide the billing address where claims information and payments should be sent, ensuring it matches your NPI or HPFIN.
6. Enter your billing tax ID, followed by the billing NPI, which is the NPI of the group or facility submitting the claim. Remember to complete a separate enrollment form for each organizational subpart.
7. If applicable, complete the pay-to NPI if it differs from the billing NPI.
8. Fill in the HealthPartners Facility ID Number (HPFIN), which is a required numeric code for all practices filing as a group or individual.
9. Provide the contact person's details, including their name, email address, and phone number.
10. If applicable, add any individual NPI(s) for Type 1, keeping this step optional.
11. Once all fields are completed, review the form for accuracy. After ensuring all information is correct, you may save changes, download, print, or share the form as needed.

Complete your documents online with ease and efficiency.