Get Enter The Appropriate 4-digit Code(s) On The Enrollment Form - Emedny

This guide provides detailed instructions on how to properly fill out the Enter The Appropriate 4-digit Code(s) On The Enrollment Form - Emedny. By following these steps, users can ensure that their enrollment forms are submitted correctly and timely, aiding in the smooth processing of their applications.

Follow the steps to complete your enrollment form effectively.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Complete all required items on the form. Make sure to use black or blue ink, and avoid red ink or white-out. Remember that all attachments should also be clear and legible.
3. Enter the appropriate 4-digit code(s) on the Enrollment Form, selecting either 0521 for Licensed Practical Nurse or 0522 for Registered Nurse, and check the corresponding box.
4. Choose one option for enrollment status: check 'New Enrollment' if the provider is not currently enrolled, 'Revalidation' if revalidation is required, or 'Reinstatement/Reactivation' if previously enrolled but not active.
5. Fill in your home address as the service address, and leave the fields for DEA Number & Dates, Type of Practice, and Place of Service blank.
6. Indicate the appropriate Association Type by entering the letter that corresponds to the individual’s role.
7. Collect necessary documents, such as a copy of your license and the Electronic Funds Transfer Authorization Form, as specified in the requirements.
8. Once all fields are filled out correctly, review the entire form for accuracy, and then save changes, download, print, or share the completed form as needed.

Start your enrollment process by completing your documents online today.