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Providers

NPI Exemption Notification Form

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.

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Information

1) Information

Please select Social Security Number ONLY if you do not have an Employer ID Number.

A 9 digit number is required. Please do not include spaces or dashes.

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Contact Information

2) Contact Information

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Provide a 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

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