Individual Provider Enrollment (Identifying Information) Page

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You use the Identifying Information page to add an individual provider's identifying information to the enrollment application.

The Identifying Information page for Individual Provider Enrollment contains the following panels:

Individual Information- Section 1 Fields

Field	Description
Last Name	Provider last name.
First Name	Provider first name.
MI	Provider middle initial.
Suffix	Provider suffix. Examples: Sr., Jr., etc.
Title	Provider's title. Examples: M.D., O.D.
Date of Birth	Provider date of birth.
Gender	Gender of the provider (male or female).
Can information about date of birth and gender be available to clients?	Select Yes or No to indicate if you want your date of birth and gender information made available to Medicaid clients or not.
State or Country of Birth	Provider state or country of birth.
SSN	The Social Security number for the individual whose information is provided on the application. Your SSN is linked to your ND provider ID number. All claims paid to your ND provider ID number are submitted as income under your SSN to the IRS. If your services may be billed as a rendering provider through a group’s employer identification number (EIN), the group through whom you plan to bill should complete a separate application and list you as an affiliated member, which links you to their EIN. You should also include this in your group affiliations when you enroll.

Field

Description

Last Name

Provider last name.

First Name

Provider first name.

Provider middle initial.

Suffix

Provider suffix.

Examples: Sr., Jr., etc.

Title

Provider's title.

Examples: M.D., O.D.

Date of Birth

Provider date of birth.

Gender

Gender of the provider (male or female).

Can information about date of birth and gender be available to clients?

Select Yes or No to indicate if you want your date of birth and gender information made available to Medicaid clients or not.

State or Country of Birth

Provider state or country of birth.

SSN

The Social Security number for the individual whose information is provided on the application. Your SSN is linked to your ND provider ID number. All claims paid to your ND provider ID number are submitted as income under your SSN to the IRS.

If your services may be billed as a rendering provider through a group’s employer identification number (EIN), the group through whom you plan to bill should complete a separate application and list you as an affiliated member, which links you to their EIN. You should also include this in your group affiliations when you enroll.

Current/Previous ND Provider # Fields

Field	Description
If you were previously enrolled as a Medicaid provider in North Dakota, to enter the current and/or previous ND provider #(s), click Add Previous ND Provider # and complete the field for each number. To edit, in the ND Previous ID # table, click the appropriate row.
ND Provider #	Current or previous ND Medicaid provider number for the service location you are now applying for.

Field

Description

If you were previously enrolled as a Medicaid provider in North Dakota, to enter the current and/or previous ND provider #(s), click Add Previous ND Provider # and complete the field for each number. To edit, in the ND Previous ID # table, click the appropriate row.

ND Provider #

Current or previous ND Medicaid provider number for the service location you are now applying for.

Previous Names Fields

Field	Description
Have you used any previous names in the past 5 years?	Answer Yes or No if you have used a different name in the past 5 years.
If you have used a different name, click Add Previous Name. To edit, in the Previous Names table, click the appropriate row.
Previous Last Name	Enter your previously used last name.
Previous First Name	Enter your previously used first name.

Field

Description

Have you used any previous names in the past 5 years?

Answer Yes or No if you have used a different name in the past 5 years.

If you have used a different name, click Add Previous Name. To edit, in the Previous Names table, click the appropriate row.

Previous Last Name

Enter your previously used last name.

Previous First Name

Enter your previously used first name.