Department of Human Services
NPI Notification
(for health care providers that cannot submit to HFS website)
DEADLINE: MAY 1, 2007
TO: DHS Division of Developmental Disabilities
FAX: (217) 558-2799
OR MAILING ADDRESS:
Department of Human Services
Division of Developmental Disabilities
319 East Madison Street, Suite 3M
Springfield, IL 62701
DATE: ______________________ # of Pages (including cover): _________
FROM: ________________________________________________________ (Contact Name-printed)
CONTACT PHONE NUMBER: ____________________________
CONTACT E-MAIL ADDRESS: ___________________________
HEALTH CARE PROVIDER INFORMATION:
LEGAL NAME OF PROVIDER: _______________________________________________
NATIONAL PROVIDER IDENTIFIER (NPI): ____________________________________
SOCIAL SECURITY NUMBER: _________________________________________
OR
FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): __________________
Attach your official NPI verification (containing legal name, NPI, taxonomy code and other information).
CONFIDENTIAL
The information contained in this facsimile transmission in intended only for the use of the individual or entity named above and those properly entitled to access the information. The facsimile transmission may contain information that is privileged, confidential, and/or exempt from disclosure under applicable law. If the reader of this transmission is not the intended or an authorized recipient, you are hereby notified that any unauthorized distribution, dissemination, duplication, or action taken in reliance on the contents of this transmission is prohibited. If you have received this transmission in error, please immediately notify the sender by telephone.
