Principal Information Form (PIF-2) Continued (Page Three)
Instructions for Completing the Principal Information Form (PIF-2) continued.
Note: This page does not apply to Ordering and Referring Providers.
Note: This page does not apply to Performing Providers.
- You must answer all of the conviction questions.
- If you selected “Yes” for any conviction question, you must explain the details in the box below the questions. Your explanation must include all of the following:
- The date of the conviction
- The state and county in which you were convicted
- The cause or case numbers for the conviction
- The crimes for which you were convicted
- You must answer all of the Child Support questions.
- If you selected Yes to the child support question, you must explain how you will meet these past-due payments.
- You must provide documentation that shows you are currently complying with your payment obligations or a court-approved agreement that specifies a compliance plan for your child support payments.
- Select “Yes” or “No” for “Are you a citizen of the United States?”
- If you selected “No”:
- Select your country of citizenship from the drop-down menu.
- Select “Yes” or “No” for “Do you have the legal right to work in the United States?”
- If you selected “Yes,” you must provide unexpired documentation that demonstrates that you have a right to reside and work in the United States.
- Click here for a list acceptable forms of identification.
- Click Continue and Save.