Facility Enrollment Checklist For Outpatient Dialysis

Category of Service Required Documentation

If you have any additional questions please contact DXC Technology Provider Enrollment at: 1-800-766-4456 COS 010/070 – Inpatient/Outpatient Hospital Services Program The EFT Agreement and W-9 are not required if a valid Payee Provider number has been established for the entity listed on the Power of Attorney for Payee and that number is listed.

  Enrollment, Outpatient