Follow the steps to successfully complete the Datalogic Vesta form.

1. Click the ‘Get Form’ button to obtain the Datalogic Vesta form, ensuring you have it ready for editing.
2. Begin by entering the legal entity name of your provider agency or financial management services agency (FMSA) in the designated field.
3. Input your Provider NPI or API number. This is critical for verifying your eligibility as a Medicaid provider.
4. Provide the Doing Business As (DBA) name if applicable, and enter your billing address, including street or PO Box number, suite or apartment number, city, state, and zip code.
5. Fill in your Provider TPI and Tax Identification Number (TIN) to ensure proper tracking and billing.
6. List your DADS 9 Digit Contract Number(s). If you have multiple, attach an additional sheet as necessary.
7. Select one EVV vendor from the list provided, ensuring you choose the vendor that aligns with your agency’s operations.
8. Indicate the date the EVV vendor was selected to keep a clear record of your choices.
9. Identify all payors with which your provider agency has contracts or receives Medicaid reimbursements by checking the appropriate boxes.
10. Designate a primary representative for EVV within your agency by completing their name, title, address, phone number, and email fields.
11. If applicable, provide contact information for the point of contact for EVV. If this is the same as the primary representative, check the corresponding box.
12. For agencies with multiple locations, list the designated point of contact for each location on the second page of the form.
13. Once all sections of the form are completed, review for accuracy. Save your changes, then download, print, or share the completed form as required.

Complete your documents online now and ensure compliance with Medicaid requirements.