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Get Novitas Solutions 8292P 2022-2024

Ed with * are required and must be completed or the request will be rejected. General Information R01-22 *Line of business: Select one from dropdown *State: Select one from dropdown Part B A (Professional) (Institutional) DC (Part DCMA J04911 TX/IHS/VA OK NM MS LA CO AR J12901 PA NJ MD DE (Part A) B) Provider Information (Must match the name for the Group/Billing Provider on file with Medicare as reported on the CMS-855 Enrollment form) *Provider name: *Contact name: *Contact telephone numb.

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