Get Pa Jm B 1000 Form

Filling out the Pa Jm B 1000 Form online can be a straightforward process when you know what to expect. This guide will walk you through each section of the form, ensuring you understand the required fields and how to complete them effectively.

Follow the steps to successfully fill out the Pa Jm B 1000 Form.

1. Click the ‘Get Form’ button to access the Pa Jm B 1000 Form online.
2. Select the request type by checking the appropriate box: Initial, Resubmission, or Please expedite this request. If you choose 'Expedited', provide a reason in the designated field.
3. Indicate the number of transports requested, remembering that a round trip equals two transports.
4. Enter the ambulance supplier or provider information, including the provider name, the National Provider Identifier (NPI), and the Provider Number (PTAN).
5. Complete the beneficiary information by entering their first and last name, date of birth (format: mm/dd/yyyy), health insurance claim (HIC) number, and gender.
6. Fill in the provider address, city, state, and zip code. Ensure to include the state where the ambulance is garaged.
7. Provide the start date of the 60-day period in the format mm/dd/yyyy.
8. In the claim information section, enter the certifying physician's name, NPI, and PTAN. Include the procedure code and any applicable modifiers.
9. Add the certifying physician's address, city, state, and zip code.
10. Fill in the requestor's name and their phone number, including extension.
11. Sign and date the form in the designated fields.
12. Once all information is complete, review for accuracy. You can then save changes, download, print, or share the form as needed.

Complete the Pa Jm B 1000 Form online today to ensure your request is processed efficiently.