Odm03620 fillable 2026

1. Click ‘Get Form’ to open the odm03620 fillable in the editor.
2. Begin with Section 1, where you will enter the Facility Name, Address, and Exiting Operator/Provider Information. Ensure all details are accurate, including the last operational day of the exiting provider.
3. Proceed to Section 2 to input the Exiting Operator/Provider Identifier Numbers. This includes your Medicaid Legacy Number, National Provider Identifier (NPI), CMS Certification Number (CCN), and Federal I.D.
4. In Section 3, provide Mailing and Contact Information. Fill in the mailing name and address where correspondence should be sent. Avoid using post office box addresses.
5. Complete Section 4 by entering Payment Information. Specify the 'Pay To' Name and Payment Address for any financial correspondence.
6. Add any Additional Information in Section 5 if necessary, then move to Section 6 to certify your submission. Include your name, title, authorized signature, and date.

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