Dmhsas Only Provider Information For Ohca Payment Purposes

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DMHSAS Only Provider Information for OHCA Payment Purposes
PROVIDER: Please fill out this form completely and have authorized representative sign. Attach a copy of either a
voided check OR a letter from your Financial Institution confirming your bank account number. For National
https://nppes.cms.hhs.gov/NPPES/Welcome.do
Provider Identifier (NPI) go to
FACILITY INFORMATION
______________________________________________________
Name of Facility or Organization
_________________________________________________________
____________________________
______________________
Doing Business As (DBA)
NPI (National Provider IdentIfier)
NPI Effective date
Type Of Organization:
For Profit Corporation
Estate/Trust
Government Owned
Limited Liability Company
Non - Profit
Partnership
Public Service Corporation
Sole Proprietorship
ADDRESSES
Service Location Address (PO Box is not acceptable):
Mail To Address (If dIfferent from Service location)
_____________________________________________________
________________________________________________________
Number and Street (PO Box is not acceptable)
Number and Street or PO Box
________________________________________________________
________________________________________________________
Suite / Bldg #
Suite / Bldg #
________________________________________________-_______
___________________________________________________-_____
City
State
Zip
4 digit zip
City
State
Zip
4 digit zip
(____)____________________________________________________
(____)____________________________________________________
Phone Number
Fax Number
Phone Number
Fax Number
Pay To Address (if different from Service Location)
________________________________________________________
Number and Street or PO Box
________________________________________________________
Suite / Bldg #
_________________________________________________-______
City
State
Zip
4 digit zip
(____)____________________________________________________
Phone Number
Fax Number
Revised 08/2009
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