Loading
Get Cms-10114 2012
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the CMS-10114 online
Completing the CMS-10114 form online is essential for healthcare providers seeking to obtain or update their National Provider Identifier (NPI). This guide offers clear, step-by-step instructions to assist you through each section of the form.
Follow the steps to accurately complete the CMS-10114 online.
- Click ‘Get Form’ button to obtain the CMS-10114 and open it in the online editor for completion.
- In Section 1, select the appropriate reason for submitting the form: 'Initial Application', 'Change of Information', 'Deactivation', or 'Reactivation'. Ensure to provide your NPI if applicable.
- In Section 1B, identify the entity type by checking either 'An individual who renders health care' or 'An organization that renders health care'. Fill out the required sections based on your choice.
- Move to Section 2 to provide identifying information. If you are an individual, include your full legal name, date of birth, and Social Security Number if applicable. Organizations should fill in their legal business name and Employer Identification Number (EIN).
- Complete Section 3 by filling in your business mailing address and practice location information. Ensure that the addresses are accurate, and do not provide residential addresses unless necessary.
- If applicable, list any other provider identification numbers in Section 3C. Skip this section if you do not have any additional identifiers.
- In Section 4, review and sign the certification statement. Include the signature of the individual practitioner for Type 1 Providers or the Authorized Official for Type 2 Organizations.
- Finally, complete Section 5 by providing a contact person's information, including their name and telephone number to facilitate any questions regarding your application.
- After filling out all sections, save your changes. You can then download, print, or share the completed CMS-10114 form as necessary.
Complete your CMS-10114 application online today to ensure a quick process.
Get form
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related links form
Acquiring CMS certification involves submitting a detailed application that meets all regulatory guidelines. After submission, your application will undergo a review process. To enhance your chances of success, consider using US Legal Forms, which provides templates and guides designed specifically for CMS-10114 certification applications.
Get This Form Now!
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.