Principal Information Form (PIF-2) Continued - Revalidation
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.
- If you selected “Person,” select “Driver’s License Number” or “Other Number.”
- This section is not required for principals that are entities.
- Complete the “Driver’s License or Other Number” field.
- If your driver’s license is expired or you do not have one, you can enter the number from any current government-issued photo identification card. The driver’s license or government-issued ID must be current on the date that the form is submitted.
- This section is not required for principals that are entities.
- Complete the “Expiration Date” field.
- If your driver’s license is expired or you do not have one, you can enter the expiration date from any current government-issued photo identification card. The driver’s license or government-issued ID must be current on the date that the form is submitted.
- This section is not required for principals that are entities.
- Complete the “State Issuer” field.
- If your driver’s license is expired or you do not have one, you can enter the state of issue from any current government-issued photo identification card or select Other. The driver’s license or government-issued ID must be current on the date that the form is submitted.
- This section is not required for principals that are entities.
- If you selected “Person,” complete the “Date of Birth” field and select a Gender.
- This section is not required for principals that are entities.
- Complete the “Previous Physical Address” field (if applicable).
- Complete the “Previous Accounting/Billing Address” field (if applicable).
- Complete the “Your title in the provider organization for which enrollment is being sought” field.
- Complete the “Your duties to the provider organization” field.
- List the duties (tasks or actions that you are required to perform) that you perform for the provider organization.
- Select a role from the “Your role in the provider organization” list, and complete the “Effective Date” field.
- Select the role that best describes your position, and enter your date of hire.
- Important: If you are a licensed health-care professional, such as a doctor, nurse, dentist, or medical director, you must enter your license information in the Licensing Information section on the previous page.
- Select “Yes” or “No” for “Do you have a relationship with a separate provider?”
- If you selected “Yes,” explain the details in the box below the question.
- List all of the TPIs, provider names, relationship to the provider, and physical locations under which you have billed or in which you were a principal. Include your current and any previous TPIs (if applicable).
- If applicable, list all of the medical entities with whom you have a contractual relationship and, if known, the NPI/API and TPIs of each entity (if applicable).
- You must answer all of the Sanction Questions.
- Your answers should address all past and current sanctions.
-  If you selected “Yes” for any of the sanction questions, you must explain the details in the box below the questions. Your explanation must include all of the following:
- The date on which the incident that led to the sanction occurred
- The state in which the incident that led to the sanction occurred
- The agency that took the action
- The program that was affected
- Click Continue and Save.