8.03: Provider Information Glossary

Provider Information Glossary


FIELD NAME DESCRIPTION
Address Mandatory - Box number, street address, etc.
Attn Optional - Name to whom daily mail will be addressed.
Bank Account Number Optional - Bank Account Number if warrant is to be mailed to a bank.
City Required, if applicable - Community
Contact Optional - Primary person to contact
County Mandatory - Provider County
Exec Director Optional - Name of the Chief Executive Officer.
Ext Optional - Telephone number extension
Fax Optional - Provider Fax Number
Line2 Required, if applicable - This field is used when ADDRESS has been entered with a box number, DBA name, etc. LINE2 must contain the street address, in accordance with the new vouchering process effective July 1, 1998.
Name Mandatory - Legal name of provider. If TIN TYPE is 02 (SSN), additional entry fields will appear to enter LAST/FIRST names and a TITLE field for titles that precede a name (e.g., DR.)
Operator Mandatory - Operator of Business (select only one)
Individual - Individual
Sole Propri - Sole Proprietorship
Partn  - Partnership
Corp - For Profit Corporation
NFP Corp  -  Not-for-Profit Corporation
Real Estate - Real Estate Agent
County  - County Agency
Oth Gov Agy  - Other Government Agency Tr/Est Trust
Hlth Care Corp - Medical/Health Care Corp
Tax Exempt - 501(a) Tax Exempt
Provider ID Mandatory - Taxpayer ID Number (IRS Designation). The Taxpayer ID Suffix is optional (i.e., store number to distinguish between providers with same taxpayer ID numbers).
Remarks Optional - For agency use only
St Mandatory - Post Office abbreviation for State.
Start Date Mandatory - Date the provider began providing services.
Status Display - Status of provider
Accepted - DHS has confirmed acceptance of provider
Submitted - data has been sent/transmitted to DHS
Pending - data not yet sent/transmitted to DHS
Rejected - DHS has rejected the provider - correct/terminate provider
TDD Optional - Provider TDD Number
Telephone Required, if applicable - Area code and general number.
Term Date Optional - Date the provider stopped providing services.
TIN Type Mandatory - Taxpayer Identification Number type:
01 - Federal Employer Identification Number
02 - Social Security Number
03 - Government Unit Code (Comptroller USAS Procedure 19.20.10)
04 - Comptroller-assigned number for certain non-reportable payments
05 - Vendor awaiting assignment of a taxpayer identification number (Comptroller USAS Procedure 19.10.15)
06 - Comptroller-assigned number for nonresident alien, foreign corporation or foreign partnership
Title Optional - Proper title of the person
Township/CA Mandatory - Provider Township/Comm Area
Warrant Mailing Name Optional - Name of person or business warrant is to be mailed to.
ZIP Required, if applicable - Post Office designation (5 or 9 digits).