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Get Ia Dhs 470-5111 2013-2026
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How to fill out the IA DHS 470-5111 online
The IA DHS 470-5111 form is an essential document for providers who order or refer services to Medicaid members. This guide provides clear instructions on completing the form online, ensuring that users can navigate each section effectively.
Follow the steps to complete the IA DHS 470-5111 form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Enter the type code in box 1. Refer to the attached listing of Iowa Medicaid provider types to identify your provider type.
- Provide the licensee name in box 2.
- Input your National Provider Identifier (NPI) number in box 3.
- Enter your professional license number in box 4. Remember to attach a copy of your license or certification documents.
- Fill in your 9-digit Social Security Number in box 5.
- Write your date of birth in box 6.
- Enter the primary service address, including city, state, and primary address phone number in box 7.
- Complete the mailing address in box 8 only if it's different from the primary address.
- In box 9, provide your Drug Enforcement Agency (DEA) number. If you do not have one, enter N/A.
- For box 10, indicate if there has ever been disciplinary action against your license by checking 'Yes' or 'No' and attach an explanation if 'Yes' is selected.
- For box 11, report if you have ever been sanctioned by Medicare or any state health program, again attaching an explanation if necessary.
- In box 12, indicate if you have been convicted of a criminal offense related to Medicare, Medicaid, or Title XX programs.
- In box 13, check whether you are employed or contracted with designated provider types. If 'Yes,' provide additional information as required.
- Enter the name, signature, email address, and phone number of the person completing the form. Ensure the practitioner signs and dates the form.
- Review all entries for accuracy. Save your changes, then download, print, or share the completed form.
Start filling out your IA DHS 470-5111 form online today!
To email Medicaid provider enrollment in Iowa, you can find the contact information on the Iowa Medicaid website. They provide an email address dedicated to provider enrollment issues. Make sure to have pertinent details ready, like your unique provider number and any reference to the IA DHS 470-5111, to streamline your communication.