Recertification enrollment: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by filling out Fields 1-6, which include your provider legal name, Legacy Provider Identifier (LPI), National Provider Identifier (NPI), Taxonomy, ZIP + 4, and Taxpayer Identification Number (TIN). Ensure accuracy as these details are crucial for your recertification.
If you are a group or clinic provider, complete Fields 7-9 for each rendering provider. Each rendering provider requires a separate form for recertification.
Common carrier transportation providers must also fill out Fields 10-11, providing necessary identification numbers.
In the contact information section (Fields 12-14), provide the name, telephone number, and email of the person who can answer questions regarding this form.
Finally, ensure that Fields 15-18 are completed with the authorized official’s name, title, signature, and date. An original signature is required to avoid processing delays.

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