470 2917-2026

1. Click ‘Get Form’ to open the 470 2917 in the editor.
2. 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.
3. 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.
4. Complete Section I by entering your contact information including email address and desired effective date for enrollment. Remember that this date cannot be retroactive.
5. 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.
6. For agencies, move to Section III. Enter your Tax ID number and indicate which services you are applying for by checking the relevant boxes.
7. 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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