Individual Non-Billing Rendering Provider Enrollment (Service) Page

You use the Service page to add or edit an individual non-billing rendering provider's primary service location and mailing information to the enrollment application.

The Service page for Individual Non-Billing Rendering Provider Enrollment page contains the following panels:

Service Location Information-Section 4
Service- Section 4
Mailing Address

You can open or close certain panels. Click The plus sign icon (the plus sign) beside a panel to open the panel. Click The minus sign icon (the minus sign) to close the panel.

Service Location Information- Section 4 Fields

Field	Description
These fields contain information about the provider's primary service location for this application. Additional locations may be added on the Submit Application - Part 2 page or after your application has been approved.
Primary Physical Address (P.O. Box not accepted)	Provider's physical street address. PO box numbers are not accepted as physical addresses. Up to 64 alphanumeric characters can be entered.
Building, Suite #, etc.	More specific address information. Up to 64 alphanumeric characters can be entered.
City	Location's city.
State	Location's state. Default: NH
Zip	Location's zip code and extension.
County	Location's county. Automatically completed after the address is validated.
To verify the address, click Validate Address. If it cannot be verified, you have the option of saving the original address, choosing one of the various versions of the corrected address, or canceling the operation.
Service Location Contact Number Fields To add a new number, click Add Numbers. Existing numbers, if any, are displayed in a table. To edit, in the Numbers table, click the appropriate row. After you edit or add numbers, on the Numbers action bar, click Save.
Phone #	Phone number associated with this location.
Fax #	Fax number associated with this location.
Location Contact Person(s) Fields To add a new contact person, click Add Contact Person. Existing contacts, if any, are displayed in a table. To edit, in the Location Contact Person(s) table, click the appropriate row. After you edit or add information, on the Contact Person action bar, click Save.
Last Name	Last name of this location's contact person.
First Name	First name of this location's contact person.
MI or Middle Initial	Middle initial of this location’s contact person.
Phone or Phone Number	Phone number of this location’s contact person.
Ext	Extension of this location’s contact person.
Fax #	Fax number of this location’s contact person.
Email	E-mail address of this location’s contact person.
Position	Position in the organization of this location’s contact person.

Service- Section 4 Fields

Field	Description
Gender Served	Select each gender the provider serves.
Age Range Served	Select each age range the provider serves.
Languages Supported	Languages supported by the provider. To move an item from the Available list to the Selected list, select the item, and then click (the right arrow). To move an item from the Selected list to the Available list, select the item, and then click (the left arrow). To select or clear multiple items, press CTRL and click the items.
Other Language	If Other was selected in the Languages Supported list, enter the other language the provider supports that is not already listed.
Is this location wheelchair accessible?	Select Yes or No to indicate if the location has wheelchair access.
Is this location TDD/TTY equipped for receiving calls for hearing impaired?	Select Yes or No to indicate if the location is equipped for the hearing impaired. If Yes is selected, an additional field is displayed to enter the phone number.
TDD/TTY Phone #	The TDD/TYY phone number for the hearing impaired, if the location has one.
Does this location provide emergency services after standard business hours?	Select Yes or No to indicate if the location provides after-hours services. If Yes is selected, an additional field is displayed to provide the phone number.
After Hours Contact Phone #	If the location does have after-hours services, the phone number to be used.

Mailing Address Fields

Field	Description
Is this mailing address the same as service location?	Indicates if the mailing address is the same as the service location address. If Yes, then the service location address is automatically copied to the mailing address fields. If No, then additional fields are displayed for you to enter the mailing address. Note: Mailing Address fields are the same address fields listed in the Service Location Information panel above.
To verify the address, click Validate Address. If it cannot be verified, you have the option of saving the original address, choosing one of the various versions of the corrected address, or canceling the operation.
Mailing Address Contact Number Fields To add a new number, click Add Numbers. Existing numbers, if any, are displayed in a table. To edit, in the Numbers table, click the appropriate row. After you edit or add numbers, on the Numbers action bar, click Save. Note: The fields in the Mailing Address Contact Numbers panel are the same as those found in the Service Location Contact Numbers panel.
Mailing Address Contact Person Fields To add a new contact, click Add Contact Person. Existing location contact persons, if any, are displayed in a table. To edit, in the Location Contact Person(s) table, click the appropriate row. After you edit or add information, on the Contact Person action bar, click Save. Note: The fields in the Mailing Address Contact Persons panel are the same as those found in the Service Location Contact Persons panel.