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W9 Form
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Error:
File upload is required.
Please attach a completed W9. Please submit enrollments through your Provider Relations staff member if you bill with a SSN as your TIN.
Is this an update or a new submission? *
Yes, we are already set-up with MHS
No, we have not been set up with MHS before
An option from "Is this an update or a new submission?" must be checked before submitting.
Provider Indiana Medicaid # *
"Confirm Provider Indiana Medicaid #" must be completed properly before submitting.
Group/Facility Name *
"Confirm Group/Facility Name" must be completed properly before submitting.
Group Indiana Medicaid # *
"Confirm Group Indiana Medicaid #" must be completed properly before submitting.
Practitioner Name
First Name *
"Confirm First Name" must be completed properly before submitting.
Last Name *
"Confirm Last Name" must be completed properly before submitting.
Practitioner Gender *
Male
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N/A (Facility)
An option from "Practitioner Gender" must be checked before submitting.
Practitioner Email Address
Tax ID # *
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Individual NPI # *
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Group NPI # *
"Confirm Group NPI #" must be completed properly before submitting.
Primary Taxonomy Code *
"Confirm Primary Taxonomy Code" must be completed properly before submitting.
Specialty
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Billing Address
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Armed Forces Americas
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Service Location Phone
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Contact First Name *
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Contact Last Name *
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Contact Title *
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Contact Phone *
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Contact Email *
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