D6_PROVIDER_CONTRACT_SUMMARY_SHEET (2).pdf
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- Attached to
- Non-Personal Healthcare Services-Physician & Other Professional Ambulatory Services for PRC Program
- Solicitation number
- 75H70725R00008
About this file
This is a Professional Medical Provider's Contract Summary Sheet template required to be completed and submitted with proposals for healthcare services to the Indian Health Service (IHS). The form collects comprehensive provider information including facility details, contact information, medical specialty, federal tax ID numbers, DUNS number, SAM.gov registration status, Medicare/Medicaid participation status and provider numbers, hospital admitting privileges, and National Provider Identifier (NPI).
The form includes sections for group practices to list multiple providers with their EIN/TIN, specialties, and billing preferences. It requires provider certification attesting to the accuracy of information and authorizing IHS to verify credentials through various medical boards and licensing agencies. The form specifically notes that EIN/TIN or SSN information will be used for claims pricing and payment processing, with suffixes required for multiple Medicare numbers or billing sites that must be referenced on IHS Form 843 Purchase-Delivery Orders.
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Text version
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
File details come from the government source that posted it. Updated .