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Medicaid Provider Application Form. This is a Utah form and can be use in Department Of Health Statewide.
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Tags: Medicaid Provider Application, Utah Statewide, Department Of Health
MEDICAID PROVIDER APPLICATION
UTAH DEPARTMENT OF HEALTH
PROVIDER NUMBER
KEEP A COPY FOR YOUR RECORDS
SEE SEPARATE SHEET FOR INSTRUCTIONS
RIGHT HALF FOR STATE USE
1. NAME
NEW
1.
APPLICATION DATE
2. BEGIN DATE
3. END DATE
2. TELEPHONE NUMBER
(
)
5. PHYSICAL LOCATION COUNTY CODE
6. TELEPHONE NUMBER
7. R-TYPE
3. SUITE #
4. NAME
4. FAX NUMBER
(
)
PAY TO ADDRESS
10. EXCEP
5. STREET OR PO BOX NUMBER
6. CITY
STATE
7. 9-DIGIT ZIP CODE
8. R-SEQ
9. RA IND
11. OUT OF STATE
Y
N
GROUP ADDRESS IF DIFFERENT THAN PAY TO ADDRESS
12. TAX NAME/GROUP PRACTICE NAME
8. TAX NAME (DBA NAME)
PHYSICAL LOCATION (IF DIFFERENT THAN PAY TO ADDRESS)
9. STREET
SUITE #
10. CITY
STATE
11. 9-DIGIT ZIP CODE
12. COUNTY
ADDRESS TO RECEIVE MEDICAID INFORMATION BULLETIN-MIBS
13. EMAIL ADDRESS
16. SUITE #
SUITE #
14. CITY
STATE
16. PROVIDER TYPE
17. SPECIALTY
A.
B.
14. ATTN:
15. STREET
13. STREET
17. CITY
STATE
PROVIDER INFORMATION
15. 9-DIGIT ZIP CODE
18. CATEGORIES OF SERVICE
18. 9-DIGIT ZIP CODE
19. RESTRICTION CODES
19. LICENSE NUMBER
21. GROUP/CLINIC PROVIDER #
20. EDI TRADING PARTNER #
21. DEA NUMBER
22. CLIA NUMBER
23. UPIN NMBER / MEDICARE #
24. NATIONAL PROV ID (NPI)
25. SSAN
26. EMPLOYER TAX ID NUMBER
27. GROUP PRACTICE NPI
20. ENROLLMENT STATUS
22. SSN
23. TAX ID
24. LICENSE NUMBER
25. LICENSE DATE
26. LICENSE BOARD
CHARGE MODES
C.
END DATE
VALUE/RATE
MODE CODE
BEGIN DATE
END DATE
VALUE/RATE
MODE CODE
END DATE
VALUE/RATE
MODE CODE
END DATE
VALUE/RATE
MODE CODE
BEGIN DATE
END DATE
VALUE/RATE
MODE CODE
BEGIN DATE
31. CATEGORIES OF SERVICE
B.
A.
MODE CODE
BEGIN DATE
30. BEGIN DATE
VALUE/RATE
BEGIN DATE
29. PROVIDER TYPE
END DATE
BEGIN DATE
28. NAME OF GROUP AFFILIATION
27.
BEGIN DATE
END DATE
VALUE/RATE
MODE CODE
BEGIN DATE
END DATE
VALUE/RATE
MODE CODE
D.
AMERICAN BOARD OF MEDICAL SPECIALTY CERTIFICATE ONLY
32. PRIMARY SPECIALTY
33. SECONDARY SPECIALTY
34. TAXONOMY
REMITTANCE STATEMENT CONTROL
35. REMIT TYPE (SUSPENDED CLAIMS)
ONCE = PRINT SUSPENDED CLAIMS
ONLY ONCE*
ALL = PRINT ALL SUSPENDED CLAIMS
NONE = DO NOT PRINT SUSPENDED CLAIMS
37. REMIT ADVIACE INDICATOR
PAPER*
CD AND PAPER
ELECTRONIC (EDI)
BOTH PAPER AND ELECTRONIC (EDI)
PAPER,ELECTRONIC (EDI) AND CD
36. REMIT PRINT SEQUENCE
RECIPIENT NAME*
RECIPIENT ID
PROVIDER NMBER
MEDICAL RECORD NUMBER
INVOICE
NOTES/COMMENTS
38. RESERVED FOR FUTURE USE
39. I CERTIFY THAT THE FOREGOING INFORMATION IS TRUE AND COMPLETE
SIGNATURE
TITLE
DATE
PHONE
REVISED 10/21/10
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