Get Ia Dhs 470-0254 2012

This guide provides step-by-step instructions on filling out the IA DHS 470-0254 form online, which is essential for provider enrollment in Iowa Medicaid. Whether you are a first-time applicant or need to update your information, this guide is designed to assist you through each section of the form.

Follow the steps to complete your Iowa Medicaid Provider Enrollment Application

1. Click ‘Get Form’ button to download the IA DHS 470-0254 form and open it in your preferred editor.
2. In Section A: General Information, begin by entering the legal name of your practice as it appears on your income tax return.
3. For the Taxpayer Identification Number (TIN), provide either the nine-digit Federal Employer Identification Number (FEIN) for businesses or the Social Security Number (SSN) if enrolling as an individual. Indicate which number you are submitting.
4. Fill in the Primary Organizational National Provider Identifier (NPI) required for billing Iowa Medicaid.
5. Enter your primary physical location details, including street number, suite number, city, state, and zip code.
6. Provide your county name, phone number, and fax number.
7. Select the type of business (individual/sole proprietor, corporation, partnership) by checking the appropriate box.
8. If your organization is a participating '340B' provider, indicate if applicable.
9. In the mailing address section, provide the address for Medicaid-related correspondence if it differs from your primary physical location.
10. Enter your email address for Medicaid-related correspondence.
11. For payment information, select your preferred method of payment (Electronic Funds Transfer or Debit Card) and enter the corresponding addresses as needed.
12. Complete any additional pharmacy-specific information if applicable.
13. In Section B, use the provided list to identify your provider type code and fill it in the designated box.
14. For each individual or institutional category that is part of the business, make additional copies of the designated page and fill them out accordingly.
15. Ensure all required licenses, certifications, and additional medical certifications are attached where necessary.
16. Review all provided information for accuracy, sign the form where indicated and include the date.
17. Once completed, save your changes, download a copy for your records, and print the form if needed.
18. Share or submit the completed form as per your organizational procedures.

Complete your IA DHS 470-0254 online to ensure a smooth provider enrollment process.