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Get and Sign Anthem W 2008-2022 Form
__ __ __ __ __ (Do Not Provide Both Numbers) __ __ __ - __ __ - __ __ __ __
Dental License Number:
National Provider Identification (NPI) Number:
(NPI Number is required for all HIPAA transactions. If you have not already registered for an NPI number- Please register at
http://www.cms.hhs.gov/NationalProvIdentStand/ or contact the CMS HIPAA Hotline at (866) 282-0659)
* If Claims Are To Be Submitted Under Associate’s Names, Please Complete One W-9 Form for Each Associate
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