D a t e o f S u b m i s s i o n : 06/04/2021 Clear Form

SECTION A - PROVIDER INFORMATION - ALL FIELDS MUST BE COMPLETED

Providers Full Name: Degree:
Last, First M.

Date Of Birth: Place Of Birth:

City, State or Country

Providers Direct Phone #: NPI Number:

Gender: Select Provider Type: Select Surgical 1st Assist? No

PA's Only

Anticipated Start Date: Enrollment Profile Type: Select

Medical or Masters School Graduation Year:

Attended:

Primary Specialty: Secondary Specialty:

Utah Medical License DEA Number:

Number: License Must Be Active If Applicable

Form Completed By:

SECTION B - PRACTICE INFORMATION

Primary Billing TIN: Select Primary Billing NPI:

Primary Service Location

by Physical Address:

Scheduling Phone #: List In Insurance Accepting New

Yes Yes
Directory? Patients?

Additional Billing TIN: Select Additional Billing NPI:

If Different Than Primary If Different Than Primary

Additional Service Location

by Physical Address:

Scheduling Phone #: List In Insurance Accepting New

Directory? Yes Yes
Patients?

Additional Billing TIN: Select Additional Billing NPI:

If Different Than Primary If Different Than Primary

Additional Service Location

by Physical Address:

Scheduling Phone #: List In Insurance Accepting New

Yes Yes
Directory? Patients?

Updated: 06/04/2021
SECTION B - PRACTICE INFORMATION CONT.
Additional Billing TIN: Select Additional Billing NPI:
If Different Than Primary If Different Than Primary

Additional Service Location

by Physical Address:

Scheduling Phone #: List In Insurance Accepting New

Yes Yes
Directory? Patients?

Additional Billing TIN: Select Additional Billing NPI:

If Different Than Primary If Different Than Primary

Additional Service Location

by Physical Address:

Scheduling Phone #: List In Insurance Accepting New

Yes Yes
Directory? Patients?

Additional Billing TIN: Select Additional Billing NPI:

If Different Than Primary If Different Than Primary

Additional Service Location

by Physical Address:

Scheduling Phone #: List In Insurance Accepting New

Yes Yes
Directory? Patients?

Additional Billing TIN: Select Additional Billing NPI:

If Different Than Primary If Different Than Primary

Additional Service Location

by Physical Address:

Scheduling Phone #: List In Insurance Accepting New

Directory?
Yes Yes
Patients?

Department and Division Supervising Provider:

Chief: NP/PA Only

Specialty Clinic: Select Clinic Name: If Yes, Select From Drop Down

All Bill Areas By Name: All Numeric Bill Areas:

Updated: 06/04/2021
SECTION C - ON-BOARDING QUESTIONNAIRE
Is Provider In Fellowship? Select

Fellowship TIN:

Will Provider Grant CMS Proxy? Select

Has Your CMS Enrollment

(Medicare/Medicaid Ever Been Revoked? Select

Limited Power of Attorney Status: Select

Limited Power of Attorney Date Signed:

Limited Power of Attorney Date Sent to

Provider Enrollment:

Therapy Providers Only – FTE Status:

End Date of Previous Employment

(If Applicable):

Additional Notes:

Submit Form

Updated: 06/04/2021
ADDENDUM A - ADDITIONAL PRACTICE LOCATIONS
Additional Billing TIN: Select Additional
Billing NPI:

Additional Service Location

by Physical Address:

Scheduling Phone #: List In Insurance Accepting New Patients? Yes

Directory?
Additional Billing TIN: Select Additional
Billing NPI:

Additional Service Location

by Physical Address:

Scheduling Phone #: List In Insurance Accepting New Patients? Yes

Directory?
Additional Billing TIN: Additional
Select Billing NPI:

Additional Service Location

by Physical Address:

Scheduling Phone #: List In Insurance Accepting New Patients? Yes

Directory?
Additional Billing TIN: Select Additional
Billing NPI:

Additional Service Location

by Physical Address:

Scheduling Phone #: List In Insurance Accepting New Patients? Yes

Directory?
Additional Billing TIN: Select Additional
Billing NPI:

Additional Service Location

by Physical Address:

Scheduling Phone #: List In Insurance Accepting New Patients? Yes

Directory?

Updated: 06/04/2021