Non-Contracted Provider Set-Up

Provider/Facility Information

Facility Name *

Billing Tax ID (TIN) *

Facility Billing/Rendering NPI (Type 2) * *1 GNPI per request

Indiana Medicaid Number *not applicable for Commercial Programs

Practicing Primary Physical Location Address, City, State, Zip *

Location Appointment Phone Number *

Facility Specialty * *i.e. Clinic, Hospital, DME, RHC, FQHC, Ambulance, etc.

Requestor Full Name *

Requestor Phone Number for Questions *

Requestor Email Contact for Questions *

Please attach a copy of your most current W9 for accurate 1099 processing. *

Group/Facility Name *

Billing Tax ID (TIN) *

Group/Facility Billing NPI (Type 2) * *1 GNPI per request

Group Indiana Medicaid Number *not applicable for Commercial Programs

Practicing Primary Physical Location Address, City, State, Zip *

Location Appointment Phone Number *

Group/Facility Specialty * *i.e. Clinic, Hospital, DME, RHC, FQHC, Ambulance, Group Practice, etc.

Practitioner Full Name *

Practitioner NPI (Type 1) *

Practitioner Indiana Medicaid Number *not applicable for Commercial Programs

Practitioner Primary Specialty *

Practitioner Primary Taxonomy *

Requestor Full Name *

Requestor Phone Number for Questions *

Requestor Email Contact for Questions *

Please attach a copy of your most current W9 for accurate 1099 processing. *