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.

Note: This is a Revalidation page. If you would like information about another application type, Click Here.

• 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.