National Government Services Criteria:  |  Change Criteria
  Medicare Part A Provider Logon Request Form

 
Section I: ACTION (required)
ADD MODIFY   DELETE 

Section II: REQUESTOR
PRIMARY CONTACT (required)   
  PHONE (required)
 
PROVIDER NAME (required)
ADDRESS (required)
CITY/STATE/ZIP (required)
  TAX EIN (required)
 
AUTHORIZED PERSON'S E-MAIL ADDRESS (required)
AUTHORIZED SIGNATURE NAME (required)
TITLE (required)

Section III: INSTITUTIONAL PROVIDER
PRIMARY
LEGACY NUMBER 		PRIMARY NATIONAL
PROVIDER ID (NPI)		 AFFILIATED
LEGACY
NUMBER(S) 		AFFILIATED
NPI(S)
 (required)
 (required)

 

Section IV: FISS OPERATOR ACCESS
 

Section V: LOGON
Operator
First Name		 Last Name Last 4
Digits of
SSN		 Logon ID
       (required) 
  1. 		(required)
 		 (required) 
  2.
  3.
  4.
  5.
  6.
  7.
  8.
  9.
10.

Section VI: Additional Primary Legacy Number(s) 

 
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