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Get and Sign 8292 Form 2019-2022
CODE/Postal Code
*STATE/Province
Ext.
*TELEPHONE #
FAX #
*EMAIL ADDRESS FOR LISTSERV AND ENROLLMENT RESPONSE
*Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)
Complete using your billing/group PTAN.
*Provider Transaction Access Number (PTAN)
*National Provider Identifier (NPI)
The PTAN/NPI reported above should NOT be the Group MEMBER PTAN/NPI. PTANs may also be known as a CMS Certification
Number. For Affiliated PTANs or National Provider...
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