I will need the following items BEFORE we start the application process.

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1. A copy of IRS EIN form. * See example attached

2. A copy of physician’s state license

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3. A certificate of insurance (COI) with National Supplier Clearinghouse as additional insured. This is your “slip & fall” insurance. Your insurance carrier will do this when you call with the address below. *See example attached

If your clinic is located east of the Mississippi River in these states:
AL, CT, DE, FL, GA, IL, IN, KY, ME, MD, MA, MI, NH, NJ, NY, NC, OH, PA, RI, SC, TN, VT, VA, WV, WI, Wash DC, PR, US Virgin Islands

Novitas Solutions, Inc
P.O. Box 3704
Mechanicsburg, PA 17055-1863

If your clinic is located west of the Mississippi River use this address as your COI

 

Palmetto GBA, AG-495
P.O. Box 100142
Columbia, SC 29202-3142

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4. A copy of a voided check for new DME company.

• This check must be from a financial institution that has no financial interest in your practice.

  • (No loans, credit cards or any debt owed to this bank)

• The account must be separate and only for new DME.

 

5. NPI number for organization.

 

6. NPI number for individual.

 

7. Need a managing member’s information. (This may be given during the conference call.)

• Date of birth

• Place of birth

• Social Security number

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Once we have all the copies of the above items, you can schedule a DME consult call. The doctor MUST be on this call to go over the process.