Get Pa Dpw Provider Enrollment Base Application 2014-2025
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How to fill out the PA DPW Provider Enrollment Base Application online
The Pennsylvania Department of Public Welfare (DPW) Provider Enrollment Base Application is a necessary document for healthcare providers seeking enrollment in Pennsylvania's Medicaid program. This guide offers clear, step-by-step instructions to help you successfully complete the application online.
Follow the steps to complete the application accurately.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Enter the complete name of the individual or facility in the designated field.
- Check the appropriate boxes for the action requests (initial enrollment, revalidation, etc.) as applicable to your situation.
- If applicable, complete the section for reactivating a provider number or adding a provider to an existing group, ensuring that all required provider numbers are entered correctly.
- Fill in your National Provider Identifier (NPI) number and taxonomy codes. If you have more than four taxonomy codes, be sure to attach an additional sheet.
- Indicate the requested effective date for your action request and provide your provider type number along with its description.
- Enter your primary specialty and any applicable specialty or sub-specialty name and code numbers.
- Provide your Social Security Number and indicate whether it is accompanied by the required documentation.
- Fill out your Tax Identification Number (TIN) if applicable, alongside the legal name as filed with the IRS.
- Complete the required sections regarding participation with Pennsylvania Medicaid Managed Care Organizations and fictitious business names if applicable.
- Fill in personal details such as date of birth, contact information for IRS documents, and business type.
- Complete licensing information if applicable, including license numbers, DEA numbers, and if applicable, CLIA certificate.
- Enter the service location address ensuring it is a physical address and not a post office box.
- Verify communication abilities in languages other than English and any ADA compliance questions.
- Sign the application in black ink, confirming that all information is accurate and complete.
- After completing the form, review the 'Did You Remember...' checklist included with the application to ensure all requirements are met.
- Return your application and all required documentation to the specified address for your provider type.
Begin your application process now to ensure compliance and timely enrollment.
The approval time for Medicaid enrollment in Pennsylvania can vary. On average, it may take several weeks from the time you submit the PA DPW Provider Enrollment Base Application until you receive a decision. Factors like the completeness of your application and the current processing workload at the state can affect the timeline. To speed things up, ensure all required documents and information are accurate and submitted promptly.
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