Get Do Not Write Here Enrollment Tracking # Sanction Dupl Hp Effective Reen Tax Idssn

This guide provides a comprehensive and user-friendly approach to filling out the Do Not Write Here Enrollment Tracking # Sanction DUPL HP Effective ReEn Tax IDSSN form online. Users will find clear, step-by-step instructions tailored to their needs.

Follow the steps to complete your enrollment form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Provide your provider name and primary service location. Ensure that the name matches what is on your Provider Contracts, and include a physical address, even if you also provide a P.O. Box.
3. Indicate whether you have applied to Medicare or another State Medicaid program recently by marking the appropriate option and providing the date if applicable.
4. Answer questions regarding any sanctions by CMS and business type. Provide the required information as instructed in the form, including your current State Pharmacy License and DEA Number.
5. Complete all sections regarding Tax ID Number and provide verification of your NPI. Ensure to attach the necessary documents, like copies of your Tax ID Number and/or Social Security Card.
6. Select the taxonomy that best describes your pharmacy services and fill out the sections on operational characteristics, such as accessibility and office hours.
7. Review all additional addresses which may include Pay-to, Remittance Advice, and Billing Service Addresses, filling them out accordingly.
8. Fill in the Authorized Signer Form and ensure the correct signatures are included for any individuals authorized to submit claims on behalf of your pharmacy.
9. Compile all necessary attachments identified in the form, ensuring that each copy of required documentation is included before submission.
10. Once you have completed all fields and compiled documents, save your changes, download a copy for your records, and prepare to send the original to the address provided in the form.

Complete your Do Not Write Here Enrollment Tracking # Sanction DUPL HP Effective ReEn Tax IDSSN form online today for a streamlined submission process.