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Practitioner name 2. Credential e.g. MD DO 3. NPI 4. Tax ID number associated with NPI 5. MassHealth Provider ID SIGNATURE OF PERSON COMPLETING THE FORM 1. Attachment 1 to MBHP Provider Alert 34 NPI Submission Form Individual Practitioner Form completed by Name Title Phone number E-mail address 1.
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01
Read the instructions carefully before filling out the form.
02
Gather all the necessary personal information, such as name, date of birth, social security number.
03
Provide the required contact information, such as address, phone number, and email.
04
Fill in the details of your healthcare provider organization, if applicable.
05
Complete the sections related to your practice location, taxonomy code, and specialty.
06
Indicate your classification and enumeration date.
07
Verify the accuracy of the entered information and review the form for any errors.
08
Sign and date the form.
09
Submit the filled-out form through the designated submission method, either online or by mail.
10
Keep a copy of the submitted form for your records.

Who needs npi submission form individual?

01
Healthcare professionals, such as physicians, dentists, chiropractors, optometrists, psychologists, etc., who provide services individually.
02
Healthcare students completing their training or clinical rotations.
03
Individuals establishing their own practice or joining an existing healthcare organization.
04
Individuals seeking to obtain or update their National Provider Identifier (NPI) record.
05
Those required by regulatory bodies or third-party payers to have an NPI.
06
Healthcare professionals participating in certain insurance plans or programs.
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NPI submission form individual is a form used to apply for or update National Provider Identifier (NPI) information for individual healthcare providers.
All healthcare providers who are individuals and are eligible for an NPI number are required to file the NPI submission form individual.
To fill out the NPI submission form individual, the healthcare provider must provide personal information, contact information, practice location details, and other relevant information as required.
The purpose of the NPI submission form individual is to help identify healthcare providers in standard electronic transactions and to improve the efficiency of the healthcare system.
The NPI submission form individual requires information such as name, date of birth, social security number, business name, practice location, contact information, and other details relevant to the healthcare provider.
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npi mbhp masshealth ccyy credential md practitioner completing submission attachment provider

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