CMS 10114 PDF

Use only blue or black ink. Do not use pencil. Failure to provide pages 1, 2, and 3 with complete and accurate information may cause your application to be returned and delay processing of your application. In addition, you may experience problems being recognized by insurers if the records in their systems do not match the information you have furnished on this form. American LegalNet, Inc.

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Learn more here. This document has been published in the Federal Register. Use the PDF linked in the document sidebar for the official electronic format. Under the Paperwork Reduction Act of the PRA , federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information including each proposed extension or reinstatement of an existing collection of information and to allow 60 days for public comment on the proposed action.

To be assured consideration, comments and recommendations must be submitted in any one of the following ways:. By regular mail. To obtain copies of a supporting statement and any related forms for the proposed collection s summarized in this notice, you may make your request using one of following:. This notice sets out a summary of the use and burden associated with the following information collections.

Interested persons are invited to send comments regarding our burden estimates or any other aspect of this collection of information, including any of the following subjects: 1 The necessity and utility of the proposed information collection for the proper performance of the agency's functions; 2 the accuracy of the estimated burden; 3 ways to enhance the quality, utility, and clarity of the information to be collected; and 4 the use of automated collection techniques or other forms of information technology to minimize the information collection burden.

Under the PRA 44 U. Section c 2 A of the PRA requires federal agencies to publish a day notice in the Federal Register concerning each proposed collection of information, including each proposed extension or reinstatement of an existing collection of information, before submitting the collection to OMB for approval. To comply with this requirement, CMS is publishing this notice.

Type of Information Collection Request: Extension of a currently approved collection;. The form is also used to deactivate their NPIs if necessary. The original application form was approved in February and has been in use since May 23, The form is available on paper or can be completed via a web-based process.

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NOM 093 SSA1 1994 PDF

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Assigned NPIs. In some cases the subparts have Provider Taxonomy Codes that may be different from that of the hospital and of each other and each subpart may require separate licensing by the State e. If the organization provider chooses to include these multiple Provider Taxonomy Codes in a request for a single NPI and later determines that the subparts should have been assigned their own NPIs with their associated Provider Taxonomy Codes the SignNow's web-based service is specifically made to simplify the arrangement of workflow and optimize the entire process of competent document management.

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Agency Information Collection Activities: Proposed Collection; Comment Request

We strongly advise that you apply for the NPI number no later than April 15 st to ensure that you receive a number before July 1 st. Below are the steps that the international residents will need to follow in order to obtain the NPI. The letter, completed application form and a copy of two proofs of identification must be mailed to the NPI Enumerator at the mailing address below:. In addition, please follow the instructions on the NPI Application for additional information about completing the application form. Please note : Sections 2B and 4B are for organizations and should not be completed by providers applying as individual providers. All other sections are applicable to individual providers and sections marked as required must be completed. When the NPI is assigned in the system, a letter will be mailed to you at the business mailing address you provide in the application.

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CMS 10114 Form

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