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Get and Sign 8292 Form 2019-2022

Get and Sign 8292 Form 2019-2022

Use a 8292 form 2019 template to make your document workflow more streamlined.

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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