OBH G Form

PLEASE READ INSTRUCTIONS BEFORE SIGNING
Dear Provider,
The following signature pages are required to enroll/link you with Medicare and Medicaid, so
that Ob Hospitalist Group can bill for services that you perform under the OBHG Tax ID number.
1. Please sign in BLUE INK ONLY
2. DO NOT DATE the forms
3. DO NOT COMPLETE any other section of the form, except where your signature is
required. Remaining fields will be populated once the forms are returned.
Multiple copies are requested because if there is an error or if the application is returned for
corrections/updates, Medicaid and Medicare will request a new original signature. Signing
three copies allows us to resubmit as needed, without having to ask you to sign another form.
If you have questions, you may reach out to the following OBHG representatives:
Cassandra McLaren
Provider Enrollment Specialist
OB Hospitalist Group
864-603-5348
cmclaren@obhg.com
Thank you,
Ob Hospitalist Group Provider Enrollment Team
Ob Hospitalist Group 10 Centimeters Drive • Mauldin, SC 29662 • P: (864) 908-3530 • F: (864) 627-9920 • www.OBHG.com
New Provider
RE: Additional Information Needed | NPI/PECOS – Medicare Enrollment
Please input your current NPI/PECOS login information below. We will use this information to submit the
855I & 855R Medicare application online via PECOS. If you have any questions, please feel free to reach out
to me at 615‐567‐7876.
NPI PECOS
(case‐sensitve)
Username
Password
Tips to resetting your NPI/PECOS Username & Password (if unknown)
1) Navigate to https://nppes.cms.hhs.gov/IAWeb/login.do
2) Select “Retrieve Forgotten User ID”
3) To have the information immediately displayed to you, input the requested information into the
right hand box. It will ask for last 4 of SSN, DOB, First and Last Name, Phone # and Home Zip
Code. Select “Continue”.
4) The User ID will be displayed on the next page. You will also have the option of creating a new
password.
5) Input the desired password.
6) If unable to reset online, you may obtain online or call the External User Services Help Desk at
(866) 484‐8049.
7) Send current login information to Cassandra McLaren (cmclaren@obhg.com) for Medicare
submission.
Sincerely,
Cassandra McLaren
OB Hospitalist Group
P:864-603-5348
cmclaren@obhg.com
SECTION 15: CERTIFICATION STATEMENT (Continued)
First Name Middle Initial Last Name M.D., D.O., etc.
Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.) Date Signed (mm/dd/yyyy)
All signatures must be original and signed in ink (blue ink preferred). Applications with signatures deemed not original will
not be processed. Stamped, faxed or copied signatures will not be accepted.
SECTION 16: FOR FUTURE USE (THIS SECTION NOT APPLICABLE)
SECTION 17: SUPPORTING DOCUMENTS

This section lists the documents that, if applicable, must be submitted with this enrollment
application. For changes, only submit documents that are applicable to the change requested. The
fee-for-service contractor may request, at any time during the enrollment process, documentation to
support or validate information reported on the application. In addition, the Medicare fee-for-service
contractor may also request documents from you, other than those identified in this section 17, as are
necessary to bill Medicare.
MANDATORY FOR ALL PROVIDER/SUPPLIER TYPES
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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0938-0685. The time required to complete
this information collection is estimated to 4 hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Baltimore, Maryland 21244-1850.
DO NOT MAIL APPLICATIONS TO THIS ADDRESS. Mailing your application to this address will significantly delay application processing.
CMS-855I (07/11) 26
SECTION 15: CERTIFICATION STATEMENT (Continued)
First Name Middle Initial Last Name M.D., D.O., etc.
Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.) Date Signed (mm/dd/yyyy)
All signatures must be original and signed in ink (blue ink preferred). Applications with signatures deemed not original will
not be processed. Stamped, faxed or copied signatures will not be accepted.
SECTION 16: FOR FUTURE USE (THIS SECTION NOT APPLICABLE)
SECTION 17: SUPPORTING DOCUMENTS

This section lists the documents that, if applicable, must be submitted with this enrollment
application. For changes, only submit documents that are applicable to the change requested. The
fee-for-service contractor may request, at any time during the enrollment process, documentation to
support or validate information reported on the application. In addition, the Medicare fee-for-service
contractor may also request documents from you, other than those identified in this section 17, as are
necessary to bill Medicare.
MANDATORY FOR ALL PROVIDER/SUPPLIER TYPES
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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0938-0685. The time required to complete
this information collection is estimated to 4 hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Baltimore, Maryland 21244-1850.
DO NOT MAIL APPLICATIONS TO THIS ADDRESS. Mailing your application to this address will significantly delay application processing.
CMS-855I (07/11) 26
PLEASE READ AND ANSWER NEXT PAGE
SECTION 3: FINAL ADVERSE LEGAL ACTIONS/CONVICTIONS
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Exclusions, Revocations, or Suspensions

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CMS-855I (07/11) 12
SECTION 3: FINAL ADVERSE LEGAL ACTIONS/CONVICTIONS (Continued)
FINAL ADVERSE LEGAL ACTION HISTORY
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FINAL ADVERSE LEGAL ACTION DATE TAKEN BY RESOLUTION
SIGNATURE: __________________________________________________________________
DATE: ________________________________________________________________________
CMS-855I (07/11) 13
SECTION 5: CONTACT PERSON INFORMATION 0QUJPOBM
If questions arise during the processing of this reassignment, the designated MAC will contact the individual
indicated below. If a contact person is not furnished, the MAC will contact the individual practitioner is Section 3.
First Name Middle Initial Last Name Jr., Sr., M.D., etc.
Contact Person Address Line 1 (Street Name And Number)
Contact Person Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town State ZIP Code +4
Telephone Number Fax Number (if applicable) Email Address (if applicable)
Relationship or Affiliation to Individual or Organization/Group (Spouse, Secretary, Attorney, Billing Agent, etc.)
NOTE: The Contact Person listed in this section will only be authorized to discuss issues concerning this
reassignment. The designated MAC will not discuss any other Medicare issues about the organization/group or
individual practitioner beyond this reassignment application with the above Contact Person.
SECTION 6: CERTIFICATION STATEMENTS AND SIGNATURES

Title XVIII of the Social Security Act prohibits payment for services provided by an individual practitioner to be
paid to another individual or organization/group unless the individual practitioner who provided the services
specifically authorizes another individual or organization/group to receive said payments in accordance with
42 CFR § 424.73 and 42 CFR § 424.80. All individual practitioners who allow another individual or organization/
group to receive payment for their services must sign the Reassignment of Medicare Benefits Statement below.
By signing this Reassignment of Medicare Benefits Statement, you are authorizing the organization/group or
individual identified in Section 2 to receive Medicare payments on your behalf.
The signature(s) below authorize the reassignment of benefits, or the termination of a reassignment of benefits,
between the individual practitioner shown in Section 3 and the organization/group shown in Section 2.
The employment of, or contract between, the individual practitioner and organization/group or individual must
be in compliance with CMS regulations and applicable Medicare program safeguard standards described in
42 CFR § 424.80.
These signatures also serve as an attestation and acknowledgment to the compliance with all laws and regulations
pertaining to the reassignment of Medicare benefits.
A. Individual Practitioner Certification Statement and Signature

Under penalty of perjury, I, the undersigned, certify that the above information is true, accurate and complete.
I understand that any misrepresentation or concealment of any information requested in this application may
subject me to liability under civil and criminal laws.
Individual Practitioner First Name (Print) Middle Initial Last Name (Print) Jr., Sr., M.D., etc.
Individual Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.) Date Signed (mm/dd/yyyy)
B. Delegated or Authorized Official of Organization/Group Certification Statement and Signature

subject me and/or the organization/group to liability under civil and criminal laws.
Delegated or Authorized Official’s First Name (Print) Middle Initial Last Name (Print) Jr., Sr., M.D., etc.
Delegated or Authorized Official’s Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.) Date Signed (mm/dd/yyyy)
All signatures must be original and signed in blue ink. Applications with signatures deemed not original or not dated will not be processed.
Stamped, faxed or copied signatures will not be accepted.
$.43

SECTION 5: CONTACT PERSON INFORMATION (Optional)
42 CFR § 424.80.


Delegated or Authorized Official’s First Name (Print) Middle Initial Last Name (Print) Jr., Sr., M.D., etc.
CLIFF LAWRENCE
Delegated or Authorized Official’s Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.) Date Signed (mm/dd/yyyy)
CMS-855R (04/16) 3
42 CFR § 424.80.


CLIFF LAWRENCE
CMS-855R (04/16) 3
42 CFR § 424.80.


CLIFF LAWRENCE
CMS-855R (04/16) 3
42 CFR § 424.80.


CLIFF LAWRENCE
CMS-855R (04/16) 3
42 CFR § 424.80.


CLIFF LAWRENCE
CMS-855R (04/16) 3
42 CFR § 424.80.


CLIFF LAWRENCE
CMS-855R (04/16) 3
42 CFR § 424.80.


CLIFF LAWRENCE
CMS-855R (04/16) 3
SECTION 5: CONTACT PERSON INFORMATION 0QUJPOBM

42 CFR § 424.80.


Delegated or Authorized Official’s First Name (Print) Middle Initial Last Name (Print) Jr., Sr., M.D., etc.
Delegated or Authorized Official’s Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.) Date Signed (mm/dd/yyyy)
$.43

42 CFR § 424.80.


CLIFF LAWRENCE
CMS-855R (04/16) 3
42 CFR § 424.80.


CLIFF LAWRENCE
CMS-855R (04/16) 3
42 CFR § 424.80.


CLIFF LAWRENCE
CMS-855R (04/16) 3
42 CFR § 424.80.


CLIFF LAWRENCE
CMS-855R (04/16) 3
42 CFR § 424.80.


CLIFF LAWRENCE
CMS-855R (04/16) 3
42 CFR § 424.80.


CLIFF LAWRENCE
CMS-855R (04/16) 3
Florida Medicaid
National Provider Identifier (NPI) Registration
Fields marked with an asterisk (*) are required.

Fields marked with a carat (^) complete as applicable.
Reason for Submission* (Check one)
 New Registration  Change Registration  Cancel Registration

Provider Name and Address
Business or Last Name*
First Name^ Middle Initial^ Jr., Sr., etc.^
Doing Business As Name^
Service Address Line 1* (Not a P.O. or Drop Box)
Service Address Line 2^
City* State* ZIP* +4^
E-mail Address* Telephone Number*
Provider Identifiers
Tax ID Type* Tax ID* Medicaid Provider ID* (or Application Tracking Number)
 SSN  FEIN
NPI Type* NPI* Taxonomy* ZIP* +4^
 IND  ORG
All electronic and paper claims must include the NPI, Taxonomy, and ZIP (+4), as entered here.
Taxonomies by Provider Type and Specialty can be obtained from the Provider Enrollment Forms page at www.mymedicaid-florida.com.
Signature*
Authorized Signature*
Printed Name of Authorized Signer* Signature Date*
Mail completed form to:

DXC Technology
PO Box 7070
Tallahassee FL 32314-7070
Alternatively: FAX completed form with a cover page to: Medicaid Provider Enrollment at 866-270-1497.
The Medicaid Provider Enrollment Fax Cover Page can obtained from the Medicaid Enrollment Wizard or the Enrollment Status page at
www.mymedicaid-florida.com, or from the Provider’s Home Page at http://home.flmmis.com.
Proprietary fax cover pages may be used, but must include the Medicaid ID or Application Tracking Number (ATN).
AHCA Form 2200-0003 (August 2017) Page 1 of 1

Florida Medicaid


 SSN  FEIN
 IND  ORG
Signature*

DXC Technology
PO Box 7070

Florida Medicaid


 SSN  FEIN
 IND  ORG
Signature*

DXC Technology
PO Box 7070

Florida Medicaid


 SSN  FEIN
 IND  ORG
Signature*

DXC Technology
PO Box 7070

For Fiscal Agent Use: ____________________
Florida Medicaid National Provider Identifier (NPI) Registration
Provider Information*
Provider Name*
Doing Business As Name (D/B/A)^

n/a
Service Address Line 1* (Street Name and Number – NOT a P.O. or Drop Box)
Service Address Line 2^ (Suite, Room, etc.)
City* State* ZIP*
Provider Identifiers Information*

Provider Federal Tax Identification Number (TIN) or Florida Medicaid Identification Number*
Employer Identification Number (EIN):*
Provider Contact Information* (for NPI Issues)

Provider Contact Name*
Telephone Number* E-mail Address^ Fax Number
National Provider Identifier (NPI)*

NPI* Taxonomy code^ (if required to map one ZIP + 4^ (if required to map one NPI to
NPI to multiple Medicaid IDs) multiple Medicaid IDs)
207V00000X
NOTE: Providers with multiple Medicaid IDs and only one NPI must indicate a unique combination of NPI and taxonomy; NPI and ZIP+4 Code; or NPI,
Taxonomy, and ZIP+4 Code to create unique cross references between their one NPI to each of their Medicaid IDs. If unique combinations are used
to cross reference one NPI to multiple Medicaid IDs, the same combinations must be used on all X-12 transactions.
Submission Information*
New Registration Change Registration Cancel Registration
X
Printed Name of Person Submitting Registration*
Printed Title of Person Submitting Registration* Submission Date*
FAX completed form to: Medicaid Provider Enrollment at 866-270-1497 (Faxed documents must have a cover sheet
showing the Medicaid Id.)
Instructions for completing the NPI Registration

Type or print legibly using blue or black ink.
x Fields marked with an asterisk (*) are required.
x Fields marked with a carat (^) are required if the information is applicable.
x Enrolled provider can access the Provider Enrollment Fax Cover Page link located on the right-hand side of
the Providers page in the Secure Web Portal.
x Applicants can access the Provider Enrollment Fax Cover Page located on the Enrollment Wizard or the
Enrollment Status Page of the Public Web Portal.
x Proprietary fax cover pages may be used but must include the Medicaid ID or Application Tracking Number
(ATN).
AHCA Form 2200-0003 (November 2013) Page 1 of 1

(11) Amendment. This agreement, application and supporting documents constitute the full and entire agreement and
understanding between the parties with respect to their relationship. No amendment is effective unless it is in writing and
signed by each party.
(12) Severability. If one or more of the provisions contained in this agreement or application shall be invalid, illegal or
unenforceable, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or
impaired.
(13) Agreement Retention. The parties agree that the agency may only retain the signature page of this agreement, and
that a copy of this standard provider agreement will be maintained by the Director of Medicaid, or his designee, and may
be reproduced as a duplicate original for any legal purpose and may also be entered into evidence as a business record.
(14) Funding. This contract is contingent upon the availability of funds.
(15) Assignability. The parties agree that neither may assign their rights under this agreement without the express written
consent of the other.
The provider, or each principal of the provider if the provider is a corporation, partnership, association, or other entity, is
required to sign this agreement. For this purpose, principals includes partners or shareholders of five (5) percent or more,
officers, directors, managers, financial records custodian, medical records custodian, subcontractors, and individuals
holding signing privileges on the depository account, and other affiliated person. A chief executive officer (CEO) or
president may sign this agreement in lieu of all principals. Failure to sign the agreement will make the agreement and
provider number voidable by the agency.
The signatories hereto represent and warrant that they have read the agreement, understand it, and are authorized to
execute it on behalf of their respective principals or co-owners. This agreement becomes null and void upon transfer of
assets; change of ownership; or upon discovery by the agency of the submission of a materially incomplete, misleading or
false provider application unless subsequently ratified or approved by the agency.
IN WITNESS WHEREOF, the undersigned have caused this agreement to be duly executed under the penalties of
perjury, and now affirms that the foregoing is true and correct.
(legibly print name of signatory) Title Signature Date
(ATTACH ADDITIONAL SIGNATURE PAGES IF NECESSARY)
Please complete the following information:
Provider’s Name:
DBA Name: n/a

Tax Identification Number:
National Provider Identifier:
Florida Medicaid Identification Number:

(For new applicants, the Medicaid ID will be entered by the fiscal agent upon approval of the
application.)
Non-Institutional MPA (August 2013) 4 of 4

(11) Amendment. This agreement, application and supporting documents constitute the full and entire agreement and
understanding between the parties with respect to their relationship. No amendment is effective unless it is in writing and
signed by each party.
(12) Severability. If one or more of the provisions contained in this agreement or application shall be invalid, illegal or
unenforceable, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or
impaired.
(13) Agreement Retention. The parties agree that the agency may only retain the signature page of this agreement, and
that a copy of this standard provider agreement will be maintained by the Director of Medicaid, or his designee, and may
be reproduced as a duplicate original for any legal purpose and may also be entered into evidence as a business record.
(14) Funding. This contract is contingent upon the availability of funds.
(15) Assignability. The parties agree that neither may assign their rights under this agreement without the express written
consent of the other.
The provider, or each principal of the provider if the provider is a corporation, partnership, association, or other entity, is
required to sign this agreement. For this purpose, principals includes partners or shareholders of five (5) percent or more,
officers, directors, managers, financial records custodian, medical records custodian, subcontractors, and individuals
holding signing privileges on the depository account, and other affiliated person. A chief executive officer (CEO) or
president may sign this agreement in lieu of all principals. Failure to sign the agreement will make the agreement and
provider number voidable by the agency.
The signatories hereto represent and warrant that they have read the agreement, understand it, and are authorized to
execute it on behalf of their respective principals or co-owners. This agreement becomes null and void upon transfer of
assets; change of ownership; or upon discovery by the agency of the submission of a materially incomplete, misleading or
false provider application unless subsequently ratified or approved by the agency.
IN WITNESS WHEREOF, the undersigned have caused this agreement to be duly executed under the penalties of
perjury, and now affirms that the foregoing is true and correct.
(ATTACH ADDITIONAL SIGNATURE PAGES IF NECESSARY)
Please complete the following information:
Provider’s Name:
DBA Name: n/a

Tax Identification Number:
National Provider Identifier:
Florida Medicaid Identification Number:

(For new applicants, the Medicaid ID will be entered by the fiscal agent upon approval of the
application.)
Non-Institutional MPA (August 2013) 4 of 4

Enrollment Application | Florida Medicaid Web Portal
Secure Web Portal Login Search
Home Recipients Managed Care Provider Services Agency Initiatives
Home ›› Provider Services ›› Enrollment ›› Enrollment Application
Enrollment Application
If you have questions about completing the online provider enrollment application, please review the Florida Medicaid Provider Enrollment Application Guide or call the Florida Medicaid fiscal agent’s Provider Enrollment
Unit at 1-800-289-7799, Option 4.
For more information on the Limited Enrollment option, please click here.
[ Refresh session ] You have approximately 59 minutes until your session will expire.
Instructions > Enrollment Type > Request Type > Before You Continue > Identifying Information > License & More Identifying Information > Contact Information > Service Location > Mailing Address > Pay To Address > Home/Corp Office Address > Xref
NPI > ATN Information > Member of the Following Groups > Owners and Operators > Applicant History
Applicant History
Has any entity or individual owner/operator ever::
1. Been convicted of a felony, had adjudication withheld on a felony, pled nolo contendere to a felony, or entered into a pre-trial agreement for a felony?
No Yes. If yes, please submit supporting documentation.

Name
2. Had any disciplinary action taken against any business or professional license held in this or any other state or surrendered a license in this or any state?

Against Whom?
What Date?
3. Been denied enrollment, been suspended or excluded from Medicare or Medicaid in any state, or been employed by a corporation, business or professional association that has ever been suspended or excluded from Medicare or Medicaid in any state?

Name
Provider Number
4. Had suspended payments from Medicare or Medicaid in any state, or been employed by a corporation, business or professional association that ever had suspended payments from Medicare or Medicaid in any state?

Name
Provider Number
5. Owes money to Medicaid or Medicare that has not been paid?

Name
Provider Number
6. Have ownership in any other Medicaid enrolled business?

Name of Other Business
Provider Number
Name of Owner
previous save & continue exit
RESOURCES SUPPORT CONNECT WITH US
Florida Medicaid Agency for Health Care Administration Contact Us
https://portal.flmmis.com/flpublic/Provider_ProviderServices/Provider_Enrollment/Provider_Enrollment_EnrollmentApplication/tabid/67/desktopdefault/+/Default.aspx[4/3/2017 3:05:00 PM]

Medicaid Provider ID: ____________________
or, Application Tracking Number (ATN)
Group Membership Authorization
Providers who will be submitting Medicaid claims under a group number must indicate the
group’s Medicaid provider number and the date they first joined the group to authorize the group
to bill on their behalf. NOTE: If the date the provider joined the group is earlier than the date the
provider and the group were both effective with Medicaid, the group link will be effective with the
later date.
If the group application is pending, list the group’s name instead of their Medicaid provider
number so this form may be matched to the group’s pending application.
Provider Name:
(Please print)
Group Medicaid Effective

Group Name: Group Tax ID: Provider ID: Date:
(Required only if (Leave blank if
(Required only if group’s provider number is group’s provider pending)
pending) number is pending)
“I authorize the group providers listed above to submit claims for services performed by myself. I
understand that, by making this request, all disbursements made for services performed by myself under
these groups will be made directly to them on my behalf.”
(Signature of Provider) Date
Group Member ship Form (July 2008)

later date.
Provider Name:
(Please print)


later date.
Provider Name:
(Please print)


later date.
Provider Name:
(Please print)


Form
(Rev. December 2014)
W-9 Request for Taxpayer Give Form to the
requester. Do not
Department of the Treasury Identification Number and Certification send to the IRS.
Internal Revenue Service
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above

See Specific Instructions on page 2.
3 Check appropriate box for federal tax classification; check only one of the following seven boxes: 4 Exemptions (codes apply only to
certain entities, not individuals; see
✔ Individual/sole proprietor or C Corporation S Corporation Partnership Trust/estate instructions on page 3):
single-member LLC
Print or type
Exempt payee code (if any)

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) a
Exemption from FATCA reporting
Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for
the tax classification of the single-member owner. code (if any)
Other (see instructions) a (Applies to accounts maintained outside the U.S.)
5 Address (number, street, and apt. or suite no.) Requester’s name and address (optional)
6 City, state, and ZIP code
7 List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other – –
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3. or
Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for Employer identification number
guidelines on whose number to enter.
–
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3.
Sign Signature of
Here U.S. person a Date a
General Instructions • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T
(tuition)
Section references are to the Internal Revenue Code unless otherwise noted. • Form 1099-C (canceled debt)
Future developments. Information about developments affecting Form W-9 (such • Form 1099-A (acquisition or abandonment of secured property)
as legislation enacted after we release it) is at www.irs.gov/fw9.
Use Form W-9 only if you are a U.S. person (including a resident alien), to
Purpose of Form provide your correct TIN.
An individual or entity (Form W-9 requester) who is required to file an information If you do not return Form W-9 to the requester with a TIN, you might be subject
return with the IRS must obtain your correct taxpayer identification number (TIN) to backup withholding. See What is backup withholding? on page 2.
which may be your social security number (SSN), individual taxpayer identification By signing the filled-out form, you:
number (ITIN), adoption taxpayer identification number (ATIN), or employer
1. Certify that the TIN you are giving is correct (or you are waiting for a number
identification number (EIN), to report on an information return the amount paid to
to be issued),
you, or other amount reportable on an information return. Examples of information
returns include, but are not limited to, the following: 2. Certify that you are not subject to backup withholding, or
• Form 1099-INT (interest earned or paid) 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If
applicable, you are also certifying that as a U.S. person, your allocable share of
• Form 1099-DIV (dividends, including those from stocks or mutual funds)
any partnership income from a U.S. trade or business is not subject to the
• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) withholding tax on foreign partners' share of effectively connected income, and
• Form 1099-B (stock or mutual fund sales and certain other transactions by 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
brokers) exempt from the FATCA reporting, is correct. See What is FATCA reporting? on
• Form 1099-S (proceeds from real estate transactions) page 2 for further information.
• Form 1099-K (merchant card and third party network transactions)
Cat. No. 10231X Form W-9 (Rev. 12-2014)

PRIVACY POLICY ACKNOWLEDGEMENT FORM
I acknowledge that I have received a copy of the privacy policies from the Florida Department of
Law Enforcement and the Federal Bureau of Investigation, which describe the exchange of
information where criminal record results will become part of the Care Provider Background
Screening Clearinghouse.
I understand and agree that I will read and comply with the guidelines contained in the privacy
policies.
Employee/Contractor Name (Printed)
Employee/Contractor Signature
Date
FLORIDA DEPARTMENT OF LAW ENFORCEMENT
NOTICE FOR APPLICANTS SUBMITTING FINGERPRINTS WHERE CRIMINAL RECORD

RESULTS WILL BECOME PART OF THE CARE PROVIDER BACKGROUND SCREENING
CLEARINGHOUSE
NOTICE OF:
• SHARING OF CRIMINAL HISTORY RECORD INFORMATION WITH SPECIFIED

AGENCIES,
• RETENTION OF FINGERPRINTS,
• PRIVACY POLICY, AND
• RIGHT TO CHALLENGE AN INCORRECT CRIMINAL HISTORY RECORD
This notice is to inform you that when you submit a set of fingerprints to the Florida Department
of Law Enforcement (FDLE) for the purpose of conducting a search for any Florida and national
criminal history records that may pertain to you, the results of that search will be returned to the
Care Provider Background Screening Clearinghouse. By submitting fingerprints, you are
authorizing the dissemination of any state and national criminal history record that may pertain
to you to the Specified Agency or Agencies from which you are seeking approval to be
employed, licensed, work under contract, or to serve as a volunteer, pursuant to the National
Child Protection Act of 1993, as amended, and Section 943.0542, Florida Statutes. "Specified
agency" means the Department of Health, the Department of Children and Family Services, the
Division of Vocational Rehabilitation within the Department of Education, the Agency for Health
Care Administration, the Department of Elder Affairs, the Department of Juvenile Justice, and
the Agency for Persons with Disabilities when these agencies are conducting state and national
criminal history background screening on persons who provide care for children or persons who
are elderly or disabled. The fingerprints submitted will be retained by FDLE and the
Clearinghouse will be notified if FDLE receives Florida arrest information on you.
Your Social Security Number (SSN) is needed to keep records accurate because other people
may have the same name and birth date. Disclosure of your SSN is imperative for the
performance of the Clearinghouse agencies’ duties in distinguishing your identity from that of
other persons whose identification information may be the same as or similar to yours.
Licensing and employing agencies are allowed to release a copy of the state and national
criminal record information to a person who requests a copy of his or her own record if the
identification of the record was based on submission of the person’s fingerprints. Therefore, if
you wish to review your record, you may request that the agency that is screening the record
provide you with a copy. After you have reviewed the criminal history record, if you believe it is
incomplete or inaccurate, you may conduct a personal review as provided in s. 943.056, F.S.,
and Rule 11C8.001, F.A.C. If national information is believed to be in error, the FBI should be
contacted at 304-625-2000. You can receive any national criminal history record that may
pertain to you directly from the FBI, pursuant to 28 CFR Sections 16.30-16.34. You have the
right to obtain a prompt determination as to the validity of your challenge before a final decision
is made about your status as an employee, volunteer, contractor, or subcontractor.
Until the criminal history background check is completed, you may be denied unsupervised
access to children, the elderly, or persons with disabilities.
The FBI’s Privacy Statement follows on a separate page and contains additional information.
1-789 (08-11-2010)
TRICARE Physician Provider Application
Resident?  Yes  No ______________________________________

 Are you employed by the U.S. Government?
Dual compensation/conflict of interest. Title 5, United States Code, section 5536 reference [bb] prohibits medical
personnel who are active duty Uniformed Service members or civilian employees of the Government from receiving
additional Government compensation above their normal pay and allowances for medical care furnished. In addition,
Uniformed service members and civilian employees of the Government are generally prohibited by law and agency
regulations and policies from participating in apparent or actual conflict of interest situations in which a potential for
personal gain exists or in which there is an appearance of impropriety or incompatibility with the performance of their
official duties or responsibilities. The Departments of Defense, Health and Human Services, and Transportation have a
responsibility, when disbursing appropriated funds in the payment of TRICARE benefits, to ensure that the laws and
regulations are not violated. Therefore, active duty Uniformed Service members (including a reserve member while on
active duty) and civilian employees of the United States Government shall not be authorized to be TRICARE providers.
While individual employees of the Government may be able to demonstrate that the furnishing of care to TRICARE
beneficiaries may not be incompatible with their official duties and responsibilities, the processing of millions of
TRICARE claims each year does not enable Program administrators to efficiently review the status of the provider on
each claim to ensure that no conflict of interest or dual compensation situation exists. The problem is further
complicated given the numerous interagency agreements (for example, resource sharing arrangements between the
Department of Defense and the Veterans Administration in the provision of health care) and other unique
arrangements which exist at individual treatment facilities around the country. While an individual provider may be
prevented from being an authorized TRICARE provider even though no conflict of interest or dual compensation
situation exists, it is essential for TRICARE to have an easily administered, uniform rule which will ensure compliance
with the existing laws and regulations. Therefore, a provider who is an active duty Uniformed Service member or
civilian employee of the Government shall not be an authorized TRICARE provider. In addition, a provider shall certify
on each TRICARE claim that he/she is not an active duty Uniformed Service member or civilian employee of the
Government.

 Are you employed or under a contract which provides for payment to the individual professional provider by an
institutional provider? If you are, your application can’t be considered. Hospital employees aren’t eligible for additional
provider numbers outside the realm of the hospital.
Signature of Provider ________________________________________________________ Date ___________
CONFLICT OF INTEREST STATEMENT

For TRICARE Providers:
Federal Law (5 U.S.C. 5536) prohibits medical personnel who are active duty members or civilian employees of the
government to receive compensation above their normal pay and allowances for medical care rendered. This
prohibition applies to TRICARE benefits whether the claim for reimbursement is filed by the individual who provided
the care, the facility in which the care was rendered, or by the sponsor/beneficiary. Claims for TRICARE benefits will
be denied in any situation where either a uniform member or civilian employee of the uniform services has the
opportunity to exert, directly or indirectly, any influence on the referral of TRICARE beneficiaries to one or more
providers on a selective basis.
Return to: WPS TRICARE East - Provider Certification
P.O. Box 7870
Madison, WI 53707-7870
Or by Fax: 608-221-7535
Please notify us of any changes related to your provider file information (Name, Address, Specialty, tax id number,
group affiliations, etc.).
21155-097-0909
No Unauthorized Copying or Distribution - WPS Proprietary and Confidential

Approver: KMinor Revised: JWebb 01/27/2018
-2-
Resident?  Yes  No ______________________________________

Government.


P.O. Box 7870
Or by Fax: 608-221-7535
21155-097-0909

-2-
Resident?  Yes  No ______________________________________

Government.


P.O. Box 7870
Or by Fax: 608-221-7535
21155-097-0909

-2-
Resident?  Yes  No ______________________________________

Government.


P.O. Box 7870
Or by Fax: 608-221-7535
21155-097-0909

-2-
Resident?  Yes  No ______________________________________

Government.


P.O. Box 7870
Or by Fax: 608-221-7535
21155-097-0909

-2-
Resident?  Yes  No ______________________________________

Government.


P.O. Box 7870
Or by Fax: 608-221-7535
21155-097-0909

-2-
Resident?  Yes  No ______________________________________

Government.


P.O. Box 7870
Or by Fax: 608-221-7535
21155-097-0909

-2-
Resident?  Yes  No ______________________________________

Government.


P.O. Box 7870
Or by Fax: 608-221-7535
21155-097-0909

-2-
Resident?  Yes  No ______________________________________

Government.


P.O. Box 7870
Or by Fax: 608-221-7535
21155-097-0909

-2-
Resident?  Yes  No ______________________________________

Government.


P.O. Box 7870
Or by Fax: 608-221-7535
21155-097-0909

-2-
Resident?  Yes  No ______________________________________

Government.


P.O. Box 7870
Or by Fax: 608-221-7535
21155-097-0909

-2-
Resident?  Yes  No ______________________________________

Government.


P.O. Box 7870
Or by Fax: 608-221-7535
21155-097-0909

-2-
Resident?  Yes  No ______________________________________

Government.


P.O. Box 7870
Or by Fax: 608-221-7535
21155-097-0909

-2-
Resident?  Yes  No ______________________________________

Government.


P.O. Box 7870
Or by Fax: 608-221-7535
21155-097-0909

-2-
Resident?  Yes  No ______________________________________

Government.


P.O. Box 7870
Or by Fax: 608-221-7535
21155-097-0909

-2-

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PLEASE READ INSTRUCTIONS BEFORE SIGNING

1. Please sign in BLUE INK ONLY

2. DO NOT DATE the forms

Ob Hospitalist Group Provider Enrollment Team

SECTION 16: FOR FUTURE USE (THIS SECTION NOT APPLICABLE)

SECTION 17: SUPPORTING DOCUMENTS

SECTION 16: FOR FUTURE USE (THIS SECTION NOT APPLICABLE)

SECTION 17: SUPPORTING DOCUMENTS

Exclusions, Revocations, or Suspensions

<(6²&RQWLQXH%HORZ 12²6NLSWR6HFWLRQ PLEASE CHECK YES OR NO

FINAL ADVERSE LEGAL ACTION DATE TAKEN BY RESOLUTION

Contact Person Address Line 1 (Street Name And Number)

Contact Person Address Line 2 (Suite, Room, Apt. #, etc.)

City/Town State ZIP Code +4

SECTION 6: CERTIFICATION STATEMENTS AND SIGNATURES

A. Individual Practitioner Certification Statement and Signature

B. Delegated or Authorized Official of Organization/Group Certification Statement and Signature

Contact Person Address Line 1 (Street Name And Number)

Contact Person Address Line 2 (Suite, Room, Apt. #, etc.)

City/Town State ZIP Code +4

SECTION 6: CERTIFICATION STATEMENTS AND SIGNATURES

A. Individual Practitioner Certification Statement and Signature

B. Delegated or Authorized Official of Organization/Group Certification Statement and Signature

Stamped, faxed or copied signatures will not be accepted.

Contact Person Address Line 1 (Street Name And Number)

Contact Person Address Line 2 (Suite, Room, Apt. #, etc.)

City/Town State ZIP Code +4

SECTION 6: CERTIFICATION STATEMENTS AND SIGNATURES

A. Individual Practitioner Certification Statement and Signature

B. Delegated or Authorized Official of Organization/Group Certification Statement and Signature

Stamped, faxed or copied signatures will not be accepted.

Contact Person Address Line 1 (Street Name And Number)

Contact Person Address Line 2 (Suite, Room, Apt. #, etc.)

City/Town State ZIP Code +4

SECTION 6: CERTIFICATION STATEMENTS AND SIGNATURES

A. Individual Practitioner Certification Statement and Signature

B. Delegated or Authorized Official of Organization/Group Certification Statement and Signature

Stamped, faxed or copied signatures will not be accepted.

Contact Person Address Line 1 (Street Name And Number)

Contact Person Address Line 2 (Suite, Room, Apt. #, etc.)

City/Town State ZIP Code +4

SECTION 6: CERTIFICATION STATEMENTS AND SIGNATURES

A. Individual Practitioner Certification Statement and Signature

B. Delegated or Authorized Official of Organization/Group Certification Statement and Signature

Stamped, faxed or copied signatures will not be accepted.

Contact Person Address Line 1 (Street Name And Number)

Contact Person Address Line 2 (Suite, Room, Apt. #, etc.)

City/Town State ZIP Code +4

SECTION 6: CERTIFICATION STATEMENTS AND SIGNATURES

A. Individual Practitioner Certification Statement and Signature

B. Delegated or Authorized Official of Organization/Group Certification Statement and Signature

Stamped, faxed or copied signatures will not be accepted.

Contact Person Address Line 1 (Street Name And Number)

Contact Person Address Line 2 (Suite, Room, Apt. #, etc.)

City/Town State ZIP Code +4

SECTION 6: CERTIFICATION STATEMENTS AND SIGNATURES

A. Individual Practitioner Certification Statement and Signature

B. Delegated or Authorized Official of Organization/Group Certification Statement and Signature

Stamped, faxed or copied signatures will not be accepted.

Contact Person Address Line 1 (Street Name And Number)

Contact Person Address Line 2 (Suite, Room, Apt. #, etc.)

City/Town State ZIP Code +4

SECTION 6: CERTIFICATION STATEMENTS AND SIGNATURES

<(6²&RQWLQXH%HORZ 12²6NLSWR6HFWLRQ PLEASE CHECK YES OR NO