PROVIDER AGREEMENT BILLING PROVIDER ENROLLMENT APPLICATION SCHEDULE B
State Form 51452 (R/1-08) / Part of State Publication 286
Indiana State Department of Health
Provider Information 1. Provider Type and Specialty
Please complete the information about your licensure as determined and maintained by the official licensing board for your provider type and specialty. Refer to ISDH Billing Provider Specialty List to determine the provider type and specialty numbers for your primary and secondary specialty. Provider Type Primary Specialty Secondary Specialty Primary Sub-Specialty ________________________________ _______________________________ _______________________________ ______________________________
Taxonomy Codes: (When mandated.)
__________________________ __________________________ __________________________ __________________________ __________________________
Secondary Sub-Specialty ______________________________
NOTE: You may select only one provider type. If you want to enroll more than one provider type, a separate application must be completed for each provider type. Primary and secondary specialties must be listed under the same provider type on the Billing Provider Specialty List. 2.
Which of the following best describes this service location?
Individual Practice Group Practice Facility or Organization Other ____________________________
Please indicate the choice that best describes the provider location being enrolled. Only one choice may be checked.
Note: For Provider Agreements covering more than one individual, please complete the attachment "Individuals Covered Under Provider Agreement". 3.
Locality
Please check the locality that best describes the service location. Please check only one item. Metropolitan Rural Urban
4.
Service Location Name and Address
Please complete the Provider Name, DBA Name, County, Telephone Number, Address, and the nine-digit ZIP Code for the site where services will be performed. You must complete a separate application for each location where services are performed, even if you bill claims from all locations under one provider number. Except for Sole proprietors who are registered with the County Recorder or use his or her own legal names for business purposes, each service location name must be the Doing Business As (DBA) name registered with the Secretary of State. The address must be a physical location. A post office box is not a valid service location address. Are you registered with the Secretary of State? Yes No County: ___________________________
Provider Name: _______________________________________________ DBA Name:
____________________________________________________________________________________
Street Address: ___________________________________________________________________________________ City: ______________________________________________ State: _____ ZIP + 4 _______________
Contact Person: _________________________________
Telephone: ________________________ Ext: _________ Fax: ________________________
E-Mail Address: _____________________________________________________________________
ISDH Provider Relations Provider Agreement Schedule B
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5.
Legal Name and Home Office Address
Please complete the contact information for the home office of the legal entity maintaining ownership of this service location. The legal name must be the current name on tax, corporation, and other legal documents, and currently registered with the Secretary of State. The address must be a physical location. A post office box is not a valid home office address. If there is more than one legal name currently used by this business entity, attach an explanation listing each name, address, and tax ID number.
Legal Name:
___________________________________________________________________________________
Street Address: ___________________________________________________________________________________ City: ______________________________________________ State: _____ ZIP + 4 _______________
Contact Person: _________________________________
Telephone: ________________________ Ext: _________ Fax: ________________________
E-Mail Address: _____________________________________________________________________
6.
Mailing Name and Address
Please complete the information for the addressing of bulletins, provider manual updates, and general correspondence, if different from the Service Location information. A post office box is acceptable for a mailing address.
Name:
________________________________________________________________________________________
Street Address: ___________________________________________________________________________________ City: _______________________________________________ State: _____ ZIP + 4 _______________
Contact Person: _________________________________
Telephone: ________________________ Ext: _________ Fax: ________________________
E-Mail Address: _____________________________________________________________________
7.
Pay To Name and Address
Please complete the information for the addressing of checks, remittance advices, and general claims payment information, if different from the Service Location information. A post office box is acceptable for this address. Name: ________________________________________________________________________________________
Street Address: ___________________________________________________________________________________ City: _______________________________________________ State: _____ ZIP + 4 _______________
Contact Person: _________________________________
Telephone: ________________________ Ext: _________ Fax: ________________________
E-Mail Address: ____________________________________________________________________ 8.
Billing Agent
(If you would have us contact your Billing Agent with questions concerning billing issues, please provide the following information.) ________________________________________________________________________________________
Name:
Street Address: ___________________________________________________________________________________ City: ________________________________________________ State _____ ZIP + 4 _______________
Contact Person: _________________________________
Telephone: ________________________ Ext: _________ Fax: ________________________
E-Mail Address: _____________________________________________________________________
ISDH Provider Relations Provider Agreement Schedule B Page 2 of 3
9. Federal Tax Identification Number: _______________________
Attach Copy of NPI Notification correspondence
Effective Date: __________________
National Provider Identification Number (NPI) _________________ Taxonomy Codes_________________
Important: Sections 10-14 require copies of the following documents for verification, as applicable.
Practitioner License from Licensing Board Clinical Laboratory Improvement Amendment (CLIA) Certificate Federal Drug Enforcement Administration (DEA) Certificate Medicare Provider Number Assignment Letter for Medicare Participation
10. License/Registration/Certification
License/Registration/Certification Number: __________________________ Issuing Board: _____________________ Effective Date: __________________________ Expiration Date: __________________________
NOTE: A copy of the license from the appropriate licensing board must be attached to the application. Failure to attach a copy of the license will result in ISDH returning this application for incomplete information.
11. CLIA Certification
Please complete this section with the information from your Clinical Laboratory Improvement Amendment (CLIA) Certificate. Certification Type: CLIA Number: Effective Date: Expiration Date: __________________________ _____________________ _____ __________________________ Waiver Provider-Performed Microscopy Procedure (PPMP) Registration Compliance Accreditation NOTE: A Copy of the certificate must be attached to the application. Failure to attach a copy of the certificate will result in denied claims for laboratory services.
12. Federal DEA Certification
Please complete this section with the information from your Federal Drug Enforcement Administration (DEA) Certificate. DEA Number: Effective Date: ________________________________________ __________________________ Expiration Date: __________________________
NOTE: A copy of the certificate must be attached to the application. Failure to attach a copy of the certificate will result in denied claims for prescriptions you prescribe.
13. Medicaid Participation
Indiana Medicaid Number: __________________________ Effective Date: ___________________________
14. Medicare Participation
Please complete the appropriate Medicare identification numbers. Medicare Number: __________________________ Medicare Number State: __________________________
Universal Provider Identification Number (UPIN): ____________________________________________________ DME Supplier Number: _________________________________________________________________________
ISDH Provider Relations Provider Agreement Schedule B
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