Free ForwardHealth National Provider Identifier Collection, F13505 - Wisconsin


File Size: 87.9 kB
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Date: January 30, 2009
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHCAA
Word Count: 356 Words, 2,348 Characters
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http://dhs.wisconsin.gov/forms/F1/F13505.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13505 (10/08)

STATE OF WISCONSIN

FORWARDHEALTH

NATIONAL PROVIDER IDENTIFIER COLLECTION
ForwardHealth requires certain information to certify providers and to authorize and pay for medical services provided to eligible members. Personally identifiable information about providers is used for purposes directly related to program administration, such as determining the certification of providers or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of payment for the services. Instructions: Type or print clearly. Submit a separate form for each provider number. Submit by fax to (608) 221-2163 or by mail to the following address: ForwardHealth Provider Maintenance 6406 Bridge Rd Madison WI 53784-0006 Section II -- Provider Number and National Provider Identifier Information Complete this form only if one of the following applies: If a provider is certified with Medicaid and has not reported the NPI for their Medicaid certification. If a provider is certified with WCDP and Medicaid and the provider's National Provider Identifier is not the same for both certifications. If a provider is certified with WCDP only and has not reported the NPI for the WCDP certification. If a provider is certified with WWWP and Medicaid and the provider's NPI is not the same for both certifications. If a provider is certified with WWWP only. Check the applicable program(s) and indicate the eight-digit Provider number and corresponding 10-digit National Provider Identifier (NPI) for the provider indicated in Section I. The NPI designated in Element 5 is the NPI to be used when conducting business with ForwardHealth. SECTION I -- PROVIDER INFORMATION 1. Name -- Provider 3. Telephone Number -- Contact Person SECTION II -- PROVIDER NUMBER AND NPI INFORMATION 4. Check the box below, if applicable only. The NPI reported on this form is: A change from previously reported data. 5. The NPI reported on this form is applicable to the following program(s): Wisconsin Medicaid, BadgerCare Plus, SeniorCare. Wisconsin Chronic Disease Program. Wisconsin Well Woman Program. 6. Provider Number 7. NPI SIGNATURE -- Authorized Representative Date Signed 2. Name -- Contact Person

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