Provider Enrollment Checklist for Provider Type 17

Provider Enrollment Checklist for Provider Type 17 Updated 03/31/2016 Provider Enrollment Checklist pv06/02/2014 1 / 1 Special Clinics - Specialty 215, Substance Abuse Agency Model (SAAM) The following is a list of required Enrollment documents for this Provider type. A copy of each document listed below must be included with your Provider Enrollment /Revalidation Packet. If you have any questions, please contact the Provider Enrollment Unit at (877) 638-3472 from 8:00 to 5:00 Monday through Friday. Documentation showing Taxpayer Identification Number (SS-4 or CP575 or W-9) Substance Abuse Prevention and Treatment Agency (SAPTA) certificate/endorsement as a Co-Occurring Capable or Co-Occurring Enhanced Program National Provider Identifier (NPI) validation: Printed page from the NPPES NPI Registry displaying the Provider s NPI or a printed copy of the email confirmation showing the Provider s NPI You do not need to submit this Checklist with your Enrollment /revalidation documents.

Provider Enrollment Checklist for Provider Type 17 Updated 03/31/2016 Provider Enrollment Checklist pv06/02/2014 1 / 1 Special Clinics - Specialty 215, Substance Abuse Agency Model (SAAM)

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