Instructions for Filling Out the Application Packet
Application Packet includes:
Section I - To Be Completed by All Providers:
(Complete all
blocks, where appropriate)
The following documents must be returned with the Application Packet:
(If you do not have a business license, please provide us a statement in writing regarding the reason why you do not have a business license.)
Name of owner:
- Name of the owner(s) of the Business
Effective Date:
- The effective date is the date the application is received in our office.
Business Name:
- List name that you will be doing business under. All payments will be paid to this name.
Business phone:
- List the phone number where normal business practices take place.
- Do not list phone numbers of billing agents.
Business Fax:
- List fax phone number.
Physical Business Address:
- List the address where the business is physically located.
Mailing Address:
- List the mailing address where you want all correspondence and checks sent.
Type of practice:
- List the type of practice that you provide. For example, medical, ambulance, dental etc.
Specialty:
- List your specialty within your practice.
NCPDP number (Pharmacies only):
- List the NCPDP (National Council for Prescription Drug Programs) number for your pharmacy. This was formerly your NABP number.
IRS number:
- List the IRS number under which this provider number will be paid. This is also referred to as your Taxpayer Identification Number (TIN).
Professional license:
- For providers that are professionally licensed to perform services, this is the license number on your license.
- A copy of the license, showing the issue and expiration date, for each licensed professional, must accompany the enrollment application.
State:
- The state in which you are licensed to perform services.
Medicare provider number:
- List the provider number under which you bill Medicare.
NPI:
- Department of Social and Health Services (DSHS) will require all providers to submit both the National Provider Identifier (NPI) and Medicaid Provider Number on ALL claim forms.
Social Security number:
- This is the SSN that payment will be made under if there is not an IRS number listed.
Signature of Authorized Agent:
- This must be the signature of the individual practitioner. In the case of a group setting, this is the signature of the clinic manager or an owner.
Section II - To be completed by each provider practicing under the above provider name/provider number and IRS number.
Section II:If the provider in Section I is a solo practice, Section II must also be completed.
Providers that are in groups must fill out Section II. Additional space is provided on Page 10.
Name:
- This is the name of the individual practicing under this number.
Professional License Number:
- For providers that are professionally licensed to perform services, this is the license number on your license. copy of the license, showing the issue and expiration date, for each licensed professional, must accompany the enrollment application.
State:
- This is the state which issued your professional license.
Medicare Provider Number:
- This is the individual provider number which you bill Medicare under as a performing provider.
National Provider Identifiers (NPI) Numbers:
- NPI Numbers are required to be listed for each individual. Department of Social and Health Services (DSHS) will require all providers to submit both the National Provider Identifier (NPI) and Medicaid Provider Number on ALL claim forms.
Type of Practice:
- List the type of service that you provide. For example, medical, ambulance, dental etc.
Speciality:
- List your specialty within your practice.
Subspecialty:
- List your subspecialty within your practice if you have one.
Social Security number:
- List your social security number.
DEA (narcotic) Number:
- List your DEA number if you have one.
Medicaid Provider Number:
- If you already have a Medicaid provider number, you must list it here.
Gender:
- Please indicate your gender.
Date of Birth:
- Please indicate date of birth.
Signature:
- This must be the signature of the individual practitioner in section II.
Section III: Must be completed by all providers
- Has any provider of service included on this agreement ever been convicted of a felony? - If you answer "yes" please include the date of the conviction, the charges and the final disposition of those charges.
- Has any provider of service included on this agreement ever been denied malpractice insurance? - If you answer "yes" please include the date of denial and the date your insurance was reinstated.
- Does any provider of service included on this agreement had any restrictions placed upon his/her license? - If you answer "yes", please include the dates and specifics of the restrictions. All Boxes must be checked and no cross-outs are allowed.
Disclosure of or Change in Ownership and Control Interest Statement
The Ownership disclosure must be completed no N/A or Non Profit. If it is a Non-Profit Org please include a list of Directors or Trustees.
- You must disclose the name and address of every person with an ownership or control interest in the disclosing entity (Section I of Enrollment Application) or in any subcontractor in which the disclosing entity has a direct or indirect ownership of 5 percent of more.
- You must also disclose if any of the owners listed in #1 are related to one another. If so, please list the owner's names and their relationship to one another.
- You must also disclose if any of the owners listed in #1 also have ownership or controlling interest in other entities. If so, please list which persons and the names and addresses of the other entities.
- If Non-Profit, you must include a list of Board of Directors or Trustees.
Frequently Asked Questions regarding Debarment
For comments or questions, contact us via email
Page modified: November 2009
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