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- Click ‘Get Form’ to open the 470 2917 in the editor.
- Begin by filling out the 'General Section'. Ensure your National Provider Identifier (NPI) is entered if applicable, and provide your legal business name as it appears on your W9 form.
- In the 'Reason for Application' section, check the appropriate box indicating whether you are a new enrollee, reactivating, changing your Tax ID, or adding services.
- Complete Section I by entering your contact information including email address and desired effective date for enrollment. Remember that this date cannot be retroactive.
- If applying as an individual for Consumer-Directed Attendant Care (CDAC), proceed to Section II. Fill in your Social Security Number and check applicable waiver types.
- For agencies, move to Section III. Enter your Tax ID number and indicate which services you are applying for by checking the relevant boxes.
- Review all entries for accuracy. If any field is not applicable, enter N/A. Ensure all required supporting documentation is attached before submission.
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