Group Provider Enrollment (Demographic) Page

You use the Demographic page to add or edit group provider's identifying information to the enrollment application.

The Demographic page for Group Provider Enrollment page contains the following panels:

SA Waiver Medium
Identifying Information- Section 1
Current/Previous NH Title XIX Provider #
Non-Profit Organization Tax Exempt Status

SA Waiver Medium Fields

Field	Description
Requested delivery media for SA letter	Letter is sent to provider's email address if INBOX is selected or mailing address if Mail is selected.

Identifying Information- Section 1 Fields

Field	Description
Group Name	Identifies the full name of the provider group.
Federal Employer Identification # (FEIN)	Identifies the Federal Employer Identification number of the provider group.
Doing Business As (DBA) Name	Official name under which the provider group is doing business.
Have you used a different DBA Name?	Select Yes or No to indicate if your group has ever operated under another business name (Doing Business As name). If Yes, enter the name in the Former DBA Name field.
Former DBA Name	Identifies the former name in which the business was operating under.
Is this application due to a change of ownership?	Select Yes or No to indicate if this application is caused by a change in group ownership. If Yes, enter the previous owner's provider number in the Provider # field.
Provider #	Previous owner's provider number. Required when the answer to change of ownership is Yes.

Current/Previous NH Title XIX Provider # Fields

Field	Description
Were you previously enrolled as a Title XIX Medicaid provider in NH?	Select Yes or No to indicate if the group was previously enrolled as a Medicaid provider in New Hampshire. If Yes, please enter the NH Title XIX Provider #.
NH Title XIX Provider #	Current or previous NH Title XIX provider number for the service location you are now applying for. Required when answering Yes to previously being enrolled as a Title XIX Medicaid provider in NH.

Field

Description

Were you previously enrolled as a Title XIX Medicaid provider in NH?

Select Yes or No to indicate if the group was previously enrolled as a Medicaid provider in New Hampshire. If Yes, please enter the NH Title XIX Provider #.

NH Title XIX Provider #

Current or previous NH Title XIX provider number for the service location you are now applying for.

Required when answering Yes to previously being enrolled as a Title XIX Medicaid provider in NH.

Non-Profit Organization Tax Exempt Status Fields

Field	Description
Is the business listed under tax-exempt status?	Select Yes or No if the group is listed as tax-exempt. If Yes, you need to attach or submit a copy of your IRS-issued exemption. The exemption form is also known as the IRS CP575 Form.