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.

1 of 2

Information

1) Information

*Tax ID:

Aetna provider identifier

Name in transactions

Address

2 of 2

Contact Information

2) Contact Information

*Last Name

*First Name

Address

Email Address

*Phone Number

Fax Number

*Comments

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

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.

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

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