ContractMedicaid Provider Application Agreement • April 22nd, 2015 • New Mexico
THIS AGREEMENT IS FOR GROUPS, ORGANIZATIONS, OR INDIVIDUAL APPLICANTS TO WHOM PAYMENTS WILL BE MADE. IF THE APPLICANT IS AN INDIVIDUAL APPLYING FOR A PROVIDER NUMBER ONLY FOR IDENTIFYING SERVICES BILLED THROUGH A GROUP PRACTICE OR OTHER ORGANIZATION AND PAYMENTS WILL BE MADE TO THAT GROUP OR ORGANIZATION, THIS FORM SHOULD NOT BE USED. USE FORM MAD 312 INSTEAD. Return completed application to: New Mexico Medicaid Project XeroxP.O. Box 27460 Albuquerque, NM 87125-7460 (1) NM Medicaid Number (if previously assigned) (2) National Provider Identifier (NPI) (3) Primary Taxonomy (4) Applicant Name (for individuals – must match license name)First Name Middle Initial Last Name Professional Title (MD, DDS, etc) (5) Business Name (DBA) (6) Federal Tax (Legal) Name (7) Physical Street Address where services are rendered (PO BOX NOT ACCEPTED) City State Zip Code County (8) Billing Office Address(MAY BE PO BOX) City State Zip Code (9) Mailing Address for official correspondence (MAY BE PO BOX) City
