EDI 8292P JH JL Novitasphere Portal Enrollment Form This form is for providers in the JH JL areas to 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the General Information section. Select your Line of Business and State from the dropdown menus provided.
3. In the Provider Information section, ensure that all required fields marked with * are completed accurately, including Provider Name, Contact Name, and Email Address.
4. Proceed to the Provider Identification section. Enter your PTAN, NPI, and TIN/EIN as these are crucial for processing your enrollment.
5. If applicable, complete the Approver Information section by providing details for both the Approver and Backup Approver.
6. Select your Reason for Request and Type of Request from the dropdowns. Ensure you choose either New Enrollment or Change Enrollment as needed.
7. Review all sections carefully before signing. Once completed, print the form, sign it, and fax or mail it to the appropriate address provided at the end of the document.

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