DIVISION OF MEDICAL SERVICES MEDICAL ASSISTANCE PROGRAM PROVIDER APPLICATION As a condition for entering into or renewing a provider agreement, all applicants must complete this provider application. A true, accurate and complete disclosure of all requested information is required by the Federal and State Regulations that govern the Medical Assistance Program. Failure of an applicant to submit the requested information or the submission of inaccurate or incomplete information may result in refusal by the Medical Assistance program to enter into, renew or continue a provider agreement with the applicant. Furthermore, the applicant is required by Federal and State Regulations to update the information submitted on the Provider Application. Whenever changes in this information occur, please submit the change in writing to: Medicaid Provider Enrollment Unit Gainwell Technologies P.O. Box 8105 Little Rock, AR 72203-8105 All dates, except where otherwise specified, should be written in the month/day/year (MMDDYY) format. Please print all information. This information is divided into sections. The following describes which sections are to be completed by the applicant: Section I All Providers Section II Facilities Only Section III Pharmacists/Registered Respiratory Therapist Only Section IV Provider Group Affiliations Electronic Fund Transfer All Providers (optional) Managed Care Agreement Primary Care Physician W-9 Tax Form All Providers Contract All Providers Ownership and Conviction Disclosure All Providers Disclosure of Significant Business Transactions All Providers DMS-652 (R. 1/21) FOR OFFICE USE ONLY Pending: Computer: OK to Key: Keyed: Maintenance Checked: Provider ID Number: Taxonomy Code: Specialty Code: Provider Type: Effective Date: SECTION I: ALL PROVIDERS This section MUST be completed by all providers. (1) Date of Application: Enter the current date in month/day/year format. ____ ____/____ ____/________ MM DD Year (2) Last Name, First Name, Middle Initial, and Title: Enter the legal name of the applicant. The title spaces are reserved for designations such as MD, DDS, CRNA or OD. If the space is insufficient, please abbreviate. If entering any other name such as an organization, corporation or facility, enter the full name of the entity in item 3. NOTE: Item 2 or 3 must be completed, BUT NOT BOTH. Last Name (3) First Name M.I. Title Group, Organization or Facility Name: Enter full name of the entity. Examples: John R. Doe, PA; Adam B. Corn, Inc.; Arkansas Emer. Phys. Group; Pulaski County Hospital; John Thompson, M. D., DBA Thompson Clinic ________________________________________________________________________________ Corporation Name ________________________________________________________________________________ Fictitious Name (Doing Business As) Must submit documentation that the above fictitious name is registered with the appropriate board within your state (i.e., Secretary of State’s, County Clerk) of the county in which the corporation’s registered office is located. (4) Application Type: Circle one of the following codes which coincide with fields 2 or 3. Each application type listed below will be required to complete Disclosure Forms (DMS-675 – Ownership and Conviction Disclosure and DMS-689 – Disclosure of Significant Business Transactions.) *NOTE: IF THE FORMS ARE NOT COMPLETED AND ATTACHED, THE APPLICATION WILL BE DENIED. 0 1 2 3 4 5 6 7 8 9 = = = = = = = = = = Individual Practitioner (i.e., physician; dentist; a licensed, registered or certified practitioner) Sole Proprietorship (This includes individually owned businesses) Government Owned Business Corporation, for profit Business Corporation, non-profit * copy of Tax Form 501 (c) (3) must accompany this application Private, for profit Private, non-profit * copy of Tax Form 501 (c) (3) must accompany this application Partnership Trust Chain * NOTE: IF THE TAX FORM IS NOT ATTACHED THE APPLICATION WILL BE DENIED. DMS-652 (R. 1/21) (5) SSN/FEIN Number: Enter the Social Security Number of the applicant or the Federal Employer Identification Number of the applicant. IF ENROLLING AN INDIVIDUAL APPLICANT THIS FIELD MUST REFLECT A SOCIAL SECURITY NUMBER. ____ _____ _____ - _____ _____ - _____ _____ _____ _____ Social Security Number NOTE: If an individual has a Federal Employee Identification Number, you will need to complete two (2) applications and two (2) contracts. One (1) as an individual and one (1) as an organization.