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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the 'Requested Effective Date' and 'Request type' sections. Choose from options like 'First-time application' or 'Join a new tax ID'.
- Complete the personal information fields, including your last name, first name, middle initial, date of birth, social security number, and gender.
- Provide your professional details such as Individual NPI #, License #, and DEA Certificate #. Ensure that you select the correct applying role from options like Nurse Practitioner or Physician Assistant.
- Fill in your primary address with street level information. Remember to indicate if this address is handicap accessible or used for telehealth services.
- Complete the applicant attestation section by signing and dating the form. Ensure all required documents are attached before submission.
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