D6_PROVIDER_CONTRACT_SUMMARY_SHEET.pdf

THIS FORM MUST BE COMPLETED AND SUBMITTED WITH PROPOSAL

Professional Medical Provider’s Contract Summary Sheet

TO BE COMPLETED AND SUBMITTED BY THE CONTRACT PROVIDER

Facility Name:

Street Address:

City: State: Zip Code:

Billing Address: (If different from the facility address) Street Address:

City: State: Zip Code:

Telephone: Fax Ph. No:

Medical Specialty Federal Employee or Tax Identification No. (EIN/TIN):

DUNS Number: Registered in SAM.gov? Yes No In Process Medicare Participating Provider: Yes No Medicare Provider Number(s):

Medicare Carrier:

Area: Prevailing Area:

National Provider Identifier (NPI):

Accepts Medicaid Patients: Yes No Medicaid Provider Number:

Admitting/Staff Privileges: Please list the hospitals for which you have admitting and/or staff privileges:

Hospital Name City State

If this is group practice, please list all providers, their EIN/TIN or SSN, Specialty, and if, under any circumstance, they will bill independent of the group practice or outside the IHS Contract. Attach spreadsheet if more than 5 providers.

Name EIN/TIN Specialty Independent Billing: Yes / No

Provider Certification – I certify (for individuals or group affiliations) that I am authorized to respond to the proposal and the above information is true to the best of my knowledge and that IHS may verify the information provided by contacting the National Practitioner Data Bank, Federation of State Medical Boards and/or those agencies responsible for licensing and board certification.

Authorized Signature of Provider:

PLEASE NOTE: The EIN/TIN, or SSN will be used to determine the pricing claims and the address to which each check (payment) is sent. A suffix must be assigned to the EIN/TIN, or SSN to create a unique number for each multiple Medicare Nos.

or multiple billing sites to which a check (payment) should be sent. The appropriate EIN/TIN, or SSN with suffix must appear in Block No. 26, d, of each IHS 843, Purchase-Delivery Order for Health Services.

TO BE COMPLETED AND SUBMITTED BY THE CONTRACT PROVIDER