Fillable Ptan Letter Request Form printable pdf download

Ptan Letter Request Form

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Insert Company Letterhead Here

PTAN Letter Request Form

Note: If you are unable to print this form on your company letterhead, please submit your

request on company letterhead and include the below information listed on the form.

This form is to be used when requesting an individual or group Provider Transaction Access

Number (PTAN). Please be aware the requests for group practice PTAN must be submitted and

signed by the Authorized or Delegated Official.*

Please complete and mail or fax** this form to:

Jurisdiction 6 Providers:

Jurisdiction K Providers:

National Government Services

Attn: Written Inquiries

P.O. Box 6475

P.O. Box 6189

Indianapolis, IN 46206-6475

Indianapolis, IN 46206-6189

Fax: 317-595-4774

Fax: 315-442-4393

** If faxing more than one request, please indicate on cover sheet

In order to verify the information is being released to the appropriate party, your inquiry must

contain all of the following information:

Complete name of the Provider/Group Practice: ______________________________________

The practice or billing address as listed in the Medicare enrollment file. Please provide

address below:

Address: _____________________________________________________________________

City: ______________________________ State: _________________ ZIP Code: _________

National Provider Identifier (NPI): _________________________________________________

Last five (5) digits of the Social Security Number/Tax Identification Number: ________________

*Signature: ____________________________________ Date of request: _________________

Printed name: _________________________________________________________________

* The Authorized or Delegated Official is the individual who has been granted the legal authority

to enroll in the Medicare Program and/or to make changes or updates to a provider’s status.

If requesting an individual provider’s PTAN, the signature must be of the provider. If requesting a

group practice PTAN, this signature must be of the Authorized or Delegated Official.

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Ptan Letter Request Form

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