Need Help Filling out this form?
Either Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)
Provider may list multiple NPI #'s if they share the Federal Tax ID listed above and Bank Account listed below. A separate Implementation form needs to be completed for each unique bank account and Federal Tax ID. Enter each NPI number on its own line.
You will receive an EFT for each Billing NPI
*Indicates a required field