Frm cst 0061-2026

The document outlines the procedures for E-Authentication Identity Proofing for new and existing businesses using the NHIC Provider Services Portal (PSP). It provides instructions for submitting required information, including business details and user identities, to ensure secure access to the portal. New businesses must complete specific pages and mail them, while existing businesses can add users via fax or email without a notary signature. The document emphasizes the importance of accurate information, security training, and compliance with CMS regulations.

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Click ‘Get Form’ to open frm cst 0061 in the editor.
Begin by filling out the 'Date' field at the top of the form. Ensure that you enter the current date accurately.
For existing PSP businesses, complete pages 2-3 only. Enter your Business/Provider Name and NPI Number(s) used for filing Medicare claims, ensuring they share the same EIN.
Fill in the Physical Business Street Address, City, State, and Zip code. This information is crucial for identification purposes.
Provide details for the Point of Contact Legal Name and their corresponding Business Street Address, City, State, and Zip code.
Complete the contact information including Phone # and E-Mail Address for both the Point of Contact and each PSP user listed.
If applicable, ensure that a Notary Confirmation section is filled out correctly with all required signatures and stamps.

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