Utah > Statewide > Department Of Health > Medicaid
Medicaid Provider Application - Utah
| Medicaid Provider Application Form. This is a Utah form and can be used in Medicaid Department Of Health Statewide . |
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MEDICAID PROVIDER APPLICATION UTAH DEPARTMENT OF HEALTH KEEP A COPY FOR YOUR RECORDS SEE SEPARATE SHEET FOR INSTRUCTIONS 1. NAME PAY TO ADDRESS 3. SUITE # 5. STREET OR PO BOX NUMBER 2. TELEPHONE NUMBER ( ) 4. FAX NUMBER ( ) RIGHT HALF FOR STATE USE NEW 4. NAME 5. PHYSICAL LOCATION COUNTY CODE 7. RTYPE 8. RSEQ 9. RA IND 6. TELEPHONE NUMBER 10. EXCEP 11. OUT OF STATE Y N 1. APPLICATION DATE 2. BEGIN DATE 3. END DATE PROVIDER NUMBER GROUP ADDRESS IF DIFFERENT THAN PAY TO ADDRESS 6. CITY STATE 7. 9DIGIT ZIP CODE 12. TAX NAME/GROUP PRACTICE NAME 13. STREET 14. CITY 9. STREET 10. CITY PHYSICAL LOCATION (IF DIFFERENT THAN PAY TO ADDRESS) SUITE # STATE 11. 9DIGIT ZIP CODE 12. COUNTY 16. PROVIDER TYPE STATE 17. SPECIALTY A. B. SUITE # 15. 9DIGIT ZIP CODE 8. TAX NAME (DBA NAME) 18. CATEGORIES OF SERVICE 19. RESTRICTION CODES 21. GROUP/CLINIC PROVIDER # 22. SSN 24. LICENSE NUMBER 27. BEGIN DATE BEGIN DATE BEGIN DATE BEGIN DATE 23. TAX ID 25. LICENSE DATE 26. LICENSE BOARD 20. ENROLLMENT STATUS MAILING ADDRESS 13. EMAIL ADDRESS 15. STREET 17. CITY STATE 14. ATTN: 16. SUITE # 18. 9DIGIT ZIP CODE PROVIDER INFORMATION 20. EDI TRADING PARTNER # 22. CLIA NUMBER 24. NATIONAL PROV ID (NPI) 26. EMPLOYER TAX ID NUMBER 28. NAME OF GROUP AFFILIATION 19. LICENSE NUMBER 21. DEA NUMBER 23. UPIN NUMBER 25. SSN 27. GROUP PRACTICE NPI / MEDICARE # CHARGE MODES END DATE VALUE/RATE END DATE END DATE END DATE END DATE END DATE END DATE END DATE VALUE/RATE VALUE/RATE VALUE/RATE VALUE/RATE VALUE/RATE VALUE/RATE VALUE/RATE MODE CODE MODE CODE MODE CODE MODE CODE MODE CODE MODE CODE MODE CODE MODE CODE BEGIN DATE 29. PROVIDER TYPE 31. CATEGORIES OF SERVICE B. 30. BEGIN DATE BEGIN DATE A. C. BEGIN DATE BEGIN DATE D. AMERICAN BOARD OF MEDICAL SPECIALTY CERTIFICATE ONLY 32. PRIMARY SPECIALTY 33. SECONDARY SPECIALTY 34. TAXONOMY REMITTANCE STATEMENT CONTROL 35. REMIT TYPE (SUSPENDED CLAIMS) 36. REMIT PRINT SEQUENCE ONCE = PRINT SUSPENDED CLAIMS RECIPIENT NAME* ONLY ONCE* RECIPIENT ID ALL = PRINT ALL SUSPENDED CLAIMS PROVIDER NMBER MEDICAL RECORD NUMBER NONE = DO NOT PRINT SUSPENDED CLAIMS INVOICE 37. RESERVED FOR FUTURE USE 38. RESERVED FOR FUTURE USE 39. I CERTIFY THAT THE FOREGOING INFORMATION IS TRUE AND COMPLETE SIGNATURE DATE NOTES/COMMENTS TITLE PHONE REVISED 11/30/2011 American LegalNet, Inc. www.FormsWorkFlow.com
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