15. Non-Institutional Medicaid Provider Agreement (NIPA)

Hand sign (NO digital signatures) and date on page 4. Also on the line saying Title put “Owner” if it is not already filled in.

On the title line where it says "Owner" print your name to the left and sign and date to the right. The signature on this form must match the signature on your Social Security card. Print your name, sign and date at the bottom.

When filling in the box area of page 4:

 

  • Provider name = your name

  • DBA is left blank

  • Tax ID number = Social Security Number

  • National Provider Identifier = NPI number

All pages of this form must be uploaded to your submission page.

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8001 Beaty Grove Dr.

Tampa, FL 33626

Office: 813.926.5454

Email: newclients@fullspectrumaba.com

Fax:     813.920.9252

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Memphis, TN 38134

Office: 901.295.2523

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