1 CMS-10114 (Rev. 06/18) DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES Form ApprovedOMB No. 0938-0931Expires: 06/21 NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORMINSTRUCTIONS FOR COMPLETING THE NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORMPlease PRINT or TYPE all information so it is legible. Use only blue or black ink. Do not use pencil. Failure to provide pages 1, 2, and 3 with complete and accurate information may cause your application to be returned and delay processing of your application. In addition, you may experience problems being recognized by insurers if the records in their systems do not match the information you have furnished on this form. American LegalNet, Inc. www.FormsWorkFlow.com Examples of individuals who need ITINs include:225Non-resident alien filing a U.S. tax return and not eligible for an SSN;225U.S. resident alien (based on days present in the United States) filing a U.S. tax return and not eligible for an SSN;225Dependent or spouse of a U.S. citizen/resident alien; and225Dependent or spouse of a non-resident alien visa holder.B.Organizations (includes Groups, Corporations and Partnerships)12262. Provide your organization222s or group222s name (legal business name used to file tax returns with the IRS) and EIN (assigned by the IRS) (Required) Please Note: If you are applying for an NPI for a subpart and the subpart does not have its own EIN, please submit the LBN and EIN for the parent organization in Sections 2B1 and 2B2 and submit the subpart name in Section 2B3. If the subpart has its own LBN and EIN (separate from the parent222s LBN and EIN), then the subpart should submit the subpart222s LBN and EIN in Section 2B1 and 2B2. In both cases, the subpart should check 221Yes222 to the subpart question in Section 1B2.3.If your organization or group uses or previously used another name, supply that 223Other Name224 in this area. (Optional)4.Mark the check box to indicate the type of 223Other Name224 used by your organization. (D/B/A Name=Doing Business As Name.) (Required if 3 iscompleted.)NOTE: A sole proprietorship does not complete this section; he/she completes Section A.SECTION 3: ADDRESSES AND OTHER INFORMATIONA.Correspondence Mailing Address Information (Required)This information will assist us in contacting you with any questions we may have regarding your application for an NPI or with other informationregarding NPI. You must provide an address and telephone number where we can contact you directly to resolve any issues that may arise during ourreview of your application. Do not report your residential address in this section unless it is also your business mailing address.B.Business Practice Location Information (Required)Provide information on the address and telephone number of your primary practice location. If you have more than one practice location, select one asthe 223primary224 location. Do not furnish information about additional locations on additional sheets of paper. Do not report your residential address inthis section unless it is also your business practice location.C.Other Provider Identification Numbers (Optional)To assist health plans in matching your NPI to your existing health plan assigned identification number(s), you may wish to list the provider identificationnumber(s) you currently use that were assigned to you by health plans. If you do not have such numbers, you are not required to obtain them in orderto be assigned an NPI. Organizations should only furnish other provider identification numbers that belong to the organization; do not list identificationnumbers that belong to health care providers who are individuals who work for the Organizations. DO NOT report SSN, ITIN, or EIN information in thissection of the form.D.Provider Taxonomy Code (Provider Type/Specialty) and License Number Information (Required) Provide your 10-digit taxonomy code. You must select a primary taxonomy code in order to facilitate aggregate reporting of providers by classification/specialization. If you need additional taxonomy codes to describe your type/classification/specialization, you may select additional codes. Information ontaxonomy codes is available at http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/.Furnish the provider222s health care license, registration, or certificate number(s) (if applicable). If issued by a State, show the State that issued the license/certificate. The following individual practitioners are required to submit a license number. (If you are a resident or intern and do not have a license or certificate, you may select the Student in an Organization Health Care Education/Training Program taxonomy code.) (If you are one of the following and do not have a license or certificate, you must enclose a letter to the Enumerator explaining why not):Certified Registered Nurse AnesthetistChiropractorClinical Nurse SpecialistClinical PsychologistDentistLicensed NurseNurse PractitionerOptometristPharmacistPhysician/OsteopathPodiatristRegistered NurseYou may use the same license, registration, or certification number for multiple taxonomies; e.g., if you are a physician with several different specialties. Do not include SSN, ITIN, EIN or NPI in this section. Do not list credentials as a taxonomy description, be specific. NOTE: A health care provider that is an organization, such as a hospital, may obtain an NPI for itself and for any subparts that it determines need to be assigned NPIs. In some cases, the subparts have Provider Taxonomy Codes that may be different from that of the hospital and of each other, and each subpart may require separate licensing by the State (e.g., General Acute Care Hospital and Psychiatric Unit). If the organization provider chooses to include these multiple Provider Taxonomy Codes in a request for a single NPI, and later determines that the subparts should have been assigned their own NPIs with their associated Provider Taxonomy Codes, the organization provider must delete from its NPPES record any Provider Taxonomy Codes that belong to the subparts who will be obtaining their own NPIs. The organization provider must do this by initiating the Change of Information option on this form.SECTION 4: CERTIFICATION STATEMENT (Required)This section is intended for the applicant to attest that he/she is aware of the requirements that must be met and maintained in order to obtain and retain an NPI. This section also requires the signature and date of signature of the 223Individual224 who is the type 1 provider, or the 223Authorized Official224 of the type 2 organization who can legally bind the provider to the laws and regulations relating to the NPI. See below to determine who within the provider qualifies as an Authorized Official. Review these requirements carefully.Authorized Official222s Information and Signature for the Organization By his/her signature, the authorized official binds the organization provider/supplier to all of the requirements listed in the Certification Statement and acknowledges that the organization provider may be denied a National Provider Identifier if any requirements are not met. This section is intended for organization providers; not health care providers who are individuals. All signatures must be original. Stamps, faxed or photocopied signatures are unacceptable. You may include multiple credentials. An authorized official is an appointed official with the legal authority to make changes and/or updates to the organization provider222s status (e.g., change of address, etc.) and to commit the organization provider to fully abide by the laws and regulations relating to the National Provider Identifier. The authorized official must be a general partner, chairman of the board, chief financial officer, chief executive officer, direct owner of 5 percent or more of the organization provider being enumerated, or must hold a position of similar status and authority within the organization.Only the authorized official(s) has the authority to sign the application on behalf of the organization provider.By signing this application for the