FS - Arkansas Medicaid PIN Application

Division of Medical Services

Medicaid Provider Enrollment Unit
Agency Intake (Fertile Soil Use Only)
Name

First NameLast Name
Date Form Received

MonthDayYear
Date
Received By:
Submission Method
Enrollment Status
DXC Technology
P.O. Box 8105 Little Rock, AR 72203-8105 501-376-2211
In state WATS 1-800-457-4454 - Fax: 501-374-0746
PRACTITIONER IDENTIFICATION NUMBER REQUEST FORM
Please select one of the following:

Physician Assistant NV (Include a W9 for the Individual)

Non-Independent Licensed Clinician (Include license) NW

Certified Behavioral Analyst Paraprofessional BP

Practitioner Name (Please print) NPI/Taxonomy Code 1346708963/253200000X
Physician Assistant NV (Include a W9 for the Individual)Resident NWNon-Independent Licensed Clinician (Include license) NWCertified Behavioral Analyst Paraprofessional BPQBHP NTPersonal Care Aide NT
Practitioner Name
Social Security Number
Date of Birth

MonthDayYear
Date
Physical Work Address
City
State
ZIP+4
County
Phone Number (Include area code)
Format: (000) 000-0000.
Mail To Address
City
State
ZIP+4
Phone Number (Indude area code)
Format: (000) 000-0000.
Individual Email Address
example@example.com
Residents Only
Place Of Residency
Effective Date of Residency

MonthDayYear
Date
Practitioner's Signature

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Date

MonthDayYear
Date
Mail or Fax this completed form to: Medicaid Provider Enrollment Unit DXC Technology P.O. Box 8105 Little Rock, AR 72203-8105 Fax Number: 501-374-0746
NPI/Taxanomy Code
Caregiver Certification

E Signature Field
Caregiver Signature*

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Date Signed*

MonthDayYear
Date
Yes
Assignment and Acknowledgment

By signing and submitting this form, I acknowledge that the information provided is true and complete. I understand that providing false or misleading information may result in denial of enrollment, termination of employment, or reporting to appropriate regulatory authorities.
Should be Empty:

Division of Medical Services

Agency Intake (Fertile Soil Use Only)

PRACTITIONER IDENTIFICATION NUMBER REQUEST FORM

Caregiver Certification