Get Pa Dpw Provider Enrollment Base Application 2011

Completing the Pennsylvania Department of Public Welfare (DPW) Provider Enrollment Base Application is an essential step for medical suppliers to participate in the Medicaid program. This guide will provide comprehensive instructions to help users fill out the form accurately and efficiently, ensuring all required information is provided.

Follow the steps to successfully complete your application.

1. Click the ‘Get Form’ button to access the PA DPW Provider Enrollment Base Application and open it within the provided editor.
2. Enter the complete name of the medical supplier in the designated field.
3. In section 2a, check the appropriate boxes to indicate the action you are requesting, such as initial enrollment or reactivation.
4. If you are reactivating a provider number, specify the 13-digit PROMISe™ provider number to be reactivated.
5. For name changes, provide both the old and new names, along with necessary verification documents from the Federal IRS.
6. Complete section 3 by entering your National Provider Identifier (NPI) Number and taxonomy codes. Attach additional sheets if necessary.
7. Enter the requested effective date for your action request in section 4.
8. Fill out your provider type number and description in section 5, and your specialty name and code number in section 6.
9. If applicable, enter sub-specialty name(s) and code number(s) in section 7.
10. Provide your Social Security Number in section 8, ensuring you include appropriate supporting documentation.
11. If you complete section 8, do not fill out section 9 regarding Tax Identification Number (TIN).
12. Complete sections 10 to 19 by providing legal names, licenses, DEA numbers, and other required information.
13. For the service location address, ensure that it is physical and not a PO Box in section 21a.
14. Indicate whether you want to receive email notifications of bulletins in section 21b.
15. Review the entire application for completeness and accuracy.
16. Sign the application in section 24, ensuring the signature is from the individual applying or a representative of the facility.
17. Upon completion, save your changes, download the form, or print and share it as needed.

Complete your PA DPW Provider Enrollment Base Application online today to ensure your participation in the Medicaid program.