National Provider Identifier (NPI)

Medical - National Provider Identifier (NPI) Exemption Notification Form

If you are exempt from the NPI regulation, you must provide us the following information so that we can continue to process your transactions without an NPI after the HIPAA compliance date.

Be sure to include a contact name and phone number so we can follow up if we require any additional information.

All fields marked with a RED asterisk(*) are required in order to proceed.

           
 #1 Please provide the following information:

*Tax ID:   
Aetna provider identifier:
Name in transactions
(billing/requesting provider)
Street:
City:
State:
Zip Code:
 #2 Contact Information

*Last Name:
*First Name:
Street:
City:
State:
Zip Code:
Email Address:
(example@sample.com)
*Phone Number: - -
(000-123-4567)
Fax Number: - -
(000-123-4567)
*Brief explanation of why you are identified in transactions in the locations usually used to identify health care providers, but are not considered a health care provider according to the NPI regulations:


 Clear Form 

 

Information Sessions

 Your request has been sent successfully if you receive a confirmation after clicking the "Submit" button.

Important! Please check this form carefully before clicking on the "Submit" button. Some browsers will not keep your information, and you will have to re-type all of it if you miss filling in any of the required fields.