Healthcare Provider Enrollment Application Medicaid Form

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The Health Care Provider Enrollment Application Medicaid Form, also known as CMS-10156, is a mandatory form that healthcare providers must complete and submit to their state Medicaid agency in order to participate in the Medicaid program. The form collects information about the provider's demographic details, ownership structure, and licensure credentials, among other things. It's a crucial step in becoming a participating provider for Medicaid patients and ensuring accurate payment and claims processing.

Streamlining enrollment process for Medicaid and other government programs by automating paperwork reduces administrative burdens, allowing staff to focus on patient care. Reduces errors and associated costs, improves compliance with program requirements, enables quicker access to reimbursement, and facilitates more efficient management of complex enrollment processes.

1. Demographic Information
2. Taxpayer Identification Number (TIN) and Business Entity Type
3. NPI Information
4. Authorized Official Contact Information
5. Facility and Location Information
6. Certification Statements
7. Business Practice Information
8. Medicare Billing Information (if applicable)
9. Medicaid Billing Information
10. Additional Requirements and Attachments