Get Enhanced Primary Care Rates Provider Attestation Form

This guide provides a clear and supportive approach to completing the Enhanced Primary Care Rates Provider Attestation Form online. By following these steps, you will be able to accurately fill out the necessary information required for enhanced rate payments effectively.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and access it in the online editing platform.
2. Begin by entering your provider name in the designated field, ensuring it matches official records for accuracy.
3. Input your individual National Provider Identifier (NPI) number in the provided area, which is necessary for identification.
4. List your Nebraska Medicaid Provider Number(s) in the corresponding field to confirm your enrollment status.
5. Select your provider type by checking either the 'Physician (MD or DO)' or 'Physician Assistant (PA)' option as applicable.
6. If you are a Physician Assistant, fill in the name and NPI of your supervising physician in the specified section.
7. Choose your provider specialty designation by checking one of the options: Family Medicine, Family Practice, Internal Medicine, or Pediatrics, and fill in any applicable subspecialty.
8. Enter your provider license number to validate your eligibility to receive the enhanced payment.
9. For the method of self-attestation, complete either section 7a or 7b. If certified, check the appropriate certifying board and attest by signing, printing your name, and dating the form. If using billing history, select the appropriate attestation and provide the same personal details.
10. Review all entered information for accuracy and clarity. Make sure that all fields are completed legibly.
11. Save your changes, then download, print, or share the completed form as necessary before sending it to the provided address for submission.

Complete your Enhanced Primary Care Rates Provider Attestation Form online to ensure eligibility for enhanced payment rates.