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Provider directory questionnaire 2026

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Click ‘Get Form’ to open the provider directory questionnaire in the editor.
Begin by entering the date and your Beacon Provider ID at the top of the form. This information is essential for identification purposes.
Fill in your provider name and corporation name, ensuring accuracy as this will be used for official records.
Indicate whether you are Medicare licensed and provide your Medicare number if applicable. This section is crucial for compliance.
Complete the billing information, including FTID, Site NPI, billing address, phone, and fax numbers. Attach a W-9 tax form as required.
Select your site number and provide detailed site information such as address, contact details, and hours of operation.
Answer questions regarding accessibility features and patient acceptance to ensure comprehensive service offerings are documented.
For each clinician at your site, complete their identifying information including name, gender, NPI number, and specialties. Ensure all fields are filled accurately.

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