Form 10-0449A REQUEST FOR NATIONAL PROVIDER IDENTIFICATION NUMBER

OMB Number: 2900-XXXX
Estimated burden: 3 min.

REQUEST FOR NATIONAL PROVIDER IDENTIFICATION NUMBER
Please complete Part I, including a wet signature, and fax this form back to:
PART I: REQUEST
The organization or individual named below is hereby requesting the National Provider Identifier (NPI) and Taxonomy Code
(Specialty/Subspecialty designation)
For the following Department of Veterans Affairs (VA) practitioner (First name, Middle initial, Last name):

For the following VA facility (indicate name of facility below):

Name of requesting organization (if not applicable, mark N/A):
Address of requester (must be physical address, not a Post Office box):

Phone number
Fax number
+ area code of requester:
+ area code of requester:
Reason for request:
reimbursement for medical care for [name veteran(s) treated; attach an extra sheet as needed]
in anticipation of need to obtain reimbursement for medical care
other (please specify)
REQUESTER'S NAME (please print):

TITLE:

SIGNATURE:

DATE:
PART II. AUTHORIZATION FOR DISCLOSURE OF INDIVIDUAL NPI DATA

I authorize VA to release the information indicated above to the organization or individual named on this request. I understand
that I may revoke this authorization, in writing, at any time except to the extent that action has already been taken to comply with
it. Written revocation is effective upon receipt by my local Privacy Officer. I understand that any authorization or revocation
may be superseded by amendment to the Privacy Act system of records containing my NPI.
NAME (please print):
SIGNATURE:

DATE:

Blanket authorization from this practitioner regarding the disclosure of his/her NPI and Taxonomy Code is on file.
PART III. RESPONSE
Date:

VA facility name
Facility NPI

Taxonomy Code

Practitioner name
Practitioner NPI
VA FORM
APR 2007

10-0449A

Taxonomy Code

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance
requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond
to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must
complete this form will average 3 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the
form. This information is used to determine the exact information you are seeking and the correct information to respond to your request for a
National Provider Number. Although this information is voluntary, failure to provide it will delay or prevent our ability to provide it to you.
Comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing the burden may be sent to VHA
Clearance Officer (19E1); Department of Veterans Affairs; 810 Vermont Ave. NW; Washington, DC 20420. DO NOT SEND YOUR REQUEST TO THIS
ADDRESS.

VA FORM
APR 2007

10-0449A