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.