Follow the steps to complete your application or reactivation.

1. Click the ‘Get Form’ button to access the ND General Individual Application/Reactivation Checklist Packet. This will allow you to open the form in the appropriate online editor.
2. Indicate whether you are submitting a new application or a reactivation by checking the appropriate box at the top of the form.
3. Provide your personal details by filling in your name, individual NPI, and primary service location details including street address, city, state, and zip code.
4. Select the billing group that will handle your services. If you are partnering with an enrolled billing group, enter the Medicaid ID and name; or, choose the unenrolled billing group option and provide your Application Tracking Number and/or NPI if applicable.
5. Designate who is filling out the form by entering their name and the date of completion.
6. Complete the provider type and specialty sections, ensuring you select the correct options that align with your taxonomy. You may require additional documentation regarding your taxonomy.
7. Request an Enrollment Effective Date by coordinating with your billing department. Note that this date is crucial as claims submitted prior may be denied.
8. Ensure that all required documents are attached, including licenses and any necessary DEA registrations, verifying the information as per your provider type.
9. If you have provided all required documents, review your form thoroughly before submission. Use the print option if you wish to retain a physical copy.
10. Submit your completed application packet and required documents as required via the designated email or fax, and keep an eye on your email for confirmation of receipt.

Take the next step towards your enrollment and complete your ND General Individual Application/Reactivation Checklist Packet online today.