Application for an additional location medicare provider number form 2025

1. Click ‘Get Form’ to open the application for an additional location Medicare provider number form in our editor.
2. Begin by filling in your personal details, including your existing Medicare provider number, name, and date of birth. Ensure you print in BLOCK LETTERS as specified.
3. Provide your postal address and contact details. Make sure to indicate if these are your preferred contact details.
4. In the residency status section, select your status when you enrolled in medical school and indicate if it has changed since your last application.
5. For the required location, enter the start and end dates, along with the physical address where services will be rendered. Specify what services you intend to provide at this location.
6. Complete the bank account details for Electronic Funds Transfer payments. Ensure that all information is accurate to avoid payment delays.
7. Review all sections carefully to ensure completeness before signing and dating the declaration at the end of the form.

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