Wv Medicaid Provider Enrollment Agreement And Signature

(The provider type is defined on the Request Information form. All subsequent specialties available to the selected provider can be added on this screen) In the first drop-down menu for «Registration Type», please select your appropriate registration type If the provider registers as a pharmacy due to a change in ownership, please enter the pharmacy details Please enter the tax name (this is the legal name registered with the IRS) (Complete this form, After receiving your business partner ID, if you wish Once the «Confirm» button has been selected, a confirmation email will be sent to the contact person entered in the application email to: EDS • Attn: EDI Department • P.O. The request will be processed within 2 to 3 weeks and depends on the receipt of all documents and the accuracy of the information provided. (Keep in mind that the shipping time can take up to five days). We recommend that you fax this expedited processing form to the number below If you are registering a freelance nurse, a physician employed by a physician or a nurse midwife, the name and NPI of the cooperating physician/supervisor must be entered. .

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