Get Ma Pe-frd-in 2017-2025

This guide provides a clear and supportive overview of how to complete the MA PE-FRD-IN online. Whether you are new to digital document management or experienced, these step-by-step instructions will help you ensure that your submission is accurate and complete.

Follow the steps to successfully fill out the MA PE-FRD-IN online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Section 1: Practitioner Information. Fill in the legal name of the practitioner, including last name, first name, and middle initial. Provide the National Provider Identifier Number (NPI), date of birth, Social Security Number (SSN), home address, telephone number, fax number, and email address. If the preferred contact is different, include their name and contact information.
3. Next, proceed to Section 2: Primary Service Location (PSL) Information. Indicate whether the PSL address is the same as the home address provided in Section 1. If not, complete the PSL street address, city, state, zip code, telephone number, fax number, and email address.
4. Then, fill out Section 3: Individuals and Entities Related to Practitioner. List individuals or entities with relevant ownership interests or relationships. Provide required details such as name, NPI, percentage of ownership, title, address, SSN or EIN, and repeat as needed for additional entities.
5. In Section 4: Disclosures, answer the questions regarding criminal offenses, exclusions from health programs, and any disciplinary actions or pending proceedings. If you answer 'yes' to any question, provide detailed explanations in Section 4B.
6. Finally, complete Section 5: Certification Statement. Carefully read the certification statement, then print your legal name, sign, and date the form. Be attentive that only your signature is acceptable.
7. After completing all sections, save your changes. You can then download, print, or share the form as needed. Ensure that you return your completed form to the specified contact email or mailing address.

Get started now to complete your MA PE-FRD-IN form online!