Follow the steps to accurately complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the facility name and specialty in the designated fields. Ensure that the facility name accurately represents the services provided.
3. Input the Medicare number, Federal Tax ID number, and National Provider Identifier (NPI) number. Remember to attach a completed W-9 Form for each Tax Identification Number.
4. Fill in the physical address fields. Include the street address, city, state, and zip code. This section is crucial for service location identification.
5. Provide contact details including phone and fax numbers, as well as the name and email of the primary contact person for the facility.
6. Next, complete the mailing address section, ensuring that it matches the format of the physical address, if it differs.
7. Move on to the billing address section. The billing name must match the claims submitted. Fill out the address, phone, fax, and contact information as required.
8. In the effective date field, specify when the new location will commence services. Ensure the date is accurate and in the correct format.
9. Collectively, the authorized signature and date fields must be completed before submission. Make sure the name is printed legibly for clarity.
10. Finally, if applicable, include additional facility contacts and their information. Review all entries for accuracy.
11. Once completed, users can save changes, download, print, or share the form as needed.

Complete your documents online with confidence and ensure accurate submissions.