Free 53215.pdf - Indiana

NATIONAL PROVIDER IDENTIFIER (NPI) INFORMATION
State Form 53215 (1-07)

INDIANA STATE DEPARTMENT OF HEALTH (ISDH) OFFICE OF HIPAA COMPLIANCE (OHC)

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INSTRUCTIONS: a. NPI Provider Information must be completed for transactions to process in a timely manner. b. Additional Taxonomy Codes: If necessary list on separate sheet and fax or e-mail with this form. 1. You will find the taxonomy listing at WPC-EDI link: http://www.wpc-edi.com/taxonomy 2. List all your taxonomy codes, on a separate sheet if necessary, that were registered with NPPES. c. Additional Tax Identification Numbers: If necessary list on separate sheet and fax or e-mail with this form. 1. Include your Provider ID number and NPI number that coincides with this Tax ID number. d. Provider Contact Information: For ISDH staff to contact provider in case of questions. e. Method of Delivery: How to send NPI information. Providers/Organizations must complete an NPI collection form or use link to report NPI for each Program Provider ID. Remember to include a copy of the National Plan and Provider Enumeration System (NPPES) certification letter or e-mail for each NPI number reported. Depending on your Program affiliation your NPI information can be filled in electronically as a Word form, a PDF form or use the link below. Fill in all sections. This form is for covered entity programs only at ISDH.
PROVIDER NPI INFORMATION

ISDH Program Name Provider Name Doing Business As (DBA) Service Location Address (number and street) City, State Program Provider ID or Provider Code NPI Number (45 CFR Part 162) ZIP code + 4 Tax ID Number (List additional #'s below ) Taxonomy Code (s) (List additional #'s below )

ADDITIONAL TAXONOMY CODES

ADDITIONAL TAX ID NUMBER

PROVIDER CONTACT INFORMATION
Electronic Organization Representative (EOR) Name Contact Name E-Mail address Miscellaneous Information Office Phone Number Fax Number

METHOD OF DELIVERY

PDF form: If you received your NPPES confirmation by US mail: Fill out the PDF form electronically, print and fax your credentials you received in the mail from NPPES to the appropriate fax numbers listed below. Word form: If you received your NPPES confirmation by e-mail: Fill out the Word form electronically. Save the completed form to your desktop or hard drive. E-mail this saved file as an attachment along with the e-mail you received from NPPES to the appropriate e-mail address listed below. HIV-MSP Link: https://npi.wellpoint.com/npi/online/onlinesubmit.jsp
Fax Number (PDF): CSHCS ­ 317-233-1342 BCCP ­ 317-233-7775 HIV-MSP - See link above Other ­ 317-233-8199 Questions regarding NPI, send correspondence to: E-Mail (Word): CSHCS ­ [email protected] BCCP ­ [email protected] HIV-MSP - See link above Other ­ [email protected]

Office of HIPAA Compliance 2 North Meridian Street, 3K Attn: NPI Project Manager Indianapolis, IN 46204-3021