Examples of NPI Compliant Transactions | NPI Exemption Notification Form

Please select your segment

Medical Dental Pharmacy Behavioral Health

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.

Please provide the following information:
*Tax ID:	EIN SSN
Aetna provider identifier:
Name in transactions (billing/requesting provider)
Street:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Contact Information
*Last Name:
*First Name:
Street:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
*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: