Form Cms-2007 - Provider Tie In Notice
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1DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Date
PROVIDER TIE-IN NOTICE
(Addition, Deletion or Correction to the Intermediary List of Providers)
NOTE: Intermediary should report any items requiring correction to the Health Insurance Regional Office.
I. Identifying Information
(Complete in all cases)
A. Name of Provider
B. Provider Number
C. Address (
D. Effective Date of
Street, City, State, Zip code)
Certification
II. New Provider Certification
A. Fiscal Year Ending Date B. Authorized Intermediary
C. Intermediary Number
Where Provider Certification Required because of a Change of Ownership—Also complete the following:
D. Effective Date of
E. Facility’s Name and Provider Number prior to Change of
F. Certification Date of
Change of Ownership
Ownership
Previous Owner
(Write “Unchanged” if applicable)
G. Intermediary for Previous Owner
H. Effective Date of Intermediary Change
(If same as item IIB, write “Unchanged”)
(Complete where IIB & IIG differ)
III. Change of Intermediary
A. Outgoing Intermediary
B. Intermediary Number C. Provider’s Fiscal Year Ending Date
D. Incoming Intermediary
E. Intermediary Number F. Effective Date of Change of
Intermediary
IV. Terminations
A. Check one
B. Effective Date C. Servicing Intermediary
D. Intermediary Number
■ ■
of Termination
Voluntary
■ ■
Involuntary
V. Remarks
(If this notice corrects a previous notice, indicate date of the notice and the item(s) reported incorrectly)
Authorizing Officer
Title
Regional Office
Form CMS-2007 (3-82)
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Parent category: Medical