E scanned - please do NOT staple. Note: Out-of-State providers must submit proof of participation in your State’s Medicaid Program. 1. Enter the complete name of Medical Supplier. 2a. Check the appropriate boxes for the action(s) you request. 2b. If you are reactivating a provider number, indicate the PROMISe™ 13 digit provider number you wish to have reactivated and complete the application as an initial enrollment. 2c. If this is a name change, indicate the old name and the new nam.
Loading
Open form follow the instructions
Easily sign the form with your finger
Send filled & signed form or save
How to fill out the PA DPW Provider Enrollment Base Application online
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.
- Click the ‘Get Form’ button to access the PA DPW Provider Enrollment Base Application and open it within the provided editor.
- Enter the complete name of the medical supplier in the designated field.
- In section 2a, check the appropriate boxes to indicate the action you are requesting, such as initial enrollment or reactivation.
- If you are reactivating a provider number, specify the 13-digit PROMISe™ provider number to be reactivated.
- For name changes, provide both the old and new names, along with necessary verification documents from the Federal IRS.
- Complete section 3 by entering your National Provider Identifier (NPI) Number and taxonomy codes. Attach additional sheets if necessary.
- Enter the requested effective date for your action request in section 4.
- Fill out your provider type number and description in section 5, and your specialty name and code number in section 6.
- If applicable, enter sub-specialty name(s) and code number(s) in section 7.
- Provide your Social Security Number in section 8, ensuring you include appropriate supporting documentation.
- If you complete section 8, do not fill out section 9 regarding Tax Identification Number (TIN).
- Complete sections 10 to 19 by providing legal names, licenses, DEA numbers, and other required information.
- For the service location address, ensure that it is physical and not a PO Box in section 21a.
- Indicate whether you want to receive email notifications of bulletins in section 21b.
- Review the entire application for completeness and accuracy.
- Sign the application in section 24, ensuring the signature is from the individual applying or a representative of the facility.
- 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.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
Online Provider Enrollment Application · Getting started with MA FFS Enrollment Training...
by K Wysen · 2003 · Cited by 2 — The Texas SCHIP and Medicaid programs have a...
Get answers to your most pressing questions about US Legal Forms API.
What is the best Medicaid insurance in PA?
The best Medicaid insurance in PA varies based on individual needs and circumstances. However, it’s essential to compare the offered benefits, services, and provider networks. Evaluating options using the PA DPW Provider Enrollment Base Application can help you make an informed choice about the best coverage for you and your family.
How to contact PA Medicaid?
You can contact PA Medicaid by calling their dedicated customer service hotline found on the Department of Human Services website. Alternatively, you can also visit your local County Assistance Office for in-person assistance. For specific inquiries about the PA DPW Provider Enrollment Base Application, inform the representative about your needs.
How to change Medicaid insurance provider PA?
To change your Medicaid insurance provider in PA, you may need to complete the PA DPW Provider Enrollment Base Application for your new plan. It's essential to review any deadlines and requirements to ensure a smooth transition. Once you've chosen a new provider, confirm its acceptance of Medicaid.
How do I email Medicaid provider enrollment in PA?
To email Medicaid provider enrollment in PA, visit the official Department of Human Services website for contact information. Usually, there's a dedicated email address for provider enrollment inquiries. If you have questions regarding the PA DPW Provider Enrollment Base Application, ensure you include details for a prompt response.
How to find Medicaid number for provider?
To find your Medicaid provider number, you may check your provider's enrollment documentation or contact the PA Medicaid program directly. Accessing the PA DPW Provider Enrollment Base Application might also help you retrieve your provider's information. Additionally, your provider should readily provide this number upon request.
How do I change my Medicaid provider in PA?
To change your Medicaid provider in PA, first, contact your current provider and inform them of your decision. Then, complete the PA DPW Provider Enrollment Base Application for your new provider. Remember to verify your eligibility and ensure your new provider accepts Medicaid before finalizing the change.
What is the provider enrollment process?
The provider enrollment process typically includes filling out the PA DPW Provider Enrollment Base Application and providing required documentation. After submission, the application will undergo review by the Department of Human Services. Once approved, you will receive confirmation of your enrollment and can start providing services.
When can I change Medicaid providers?
You can change Medicaid providers at any time during the year. However, it is most common to make changes during the annual open enrollment period. Ensure you have completed the PA DPW Provider Enrollment Base Application to facilitate a smooth transition to your new provider.
What is the phone number for PA enrollment?
The phone number for PA Medicaid enrollment can be found on the Pennsylvania Department of Human Services website, as it varies based on specific inquiries. They provide dedicated lines for provider questions, beneficiary support, and enrollment services. For the most accurate information, visiting the PA DPW Provider Enrollment Base Application is highly recommended.
What is a provider enrollment information form?
A provider enrollment information form is a document that healthcare providers in Pennsylvania use to register and participate in the Medicaid program. This form collects essential information about the provider's qualifications, services, and billing procedures. Completing this form accurately is crucial for seamless enrollment and ensuring compliance with state regulations, available through the PA DPW Provider Enrollment Base Application.
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
If you believe that this page should be taken down, please follow our DMCA take down process here.
This form is available in several versions. Select the version you need from the drop-down list below.