Tax Reporting Type

• Select the appropriate radio button to indicate if you report your SSN (Social Security Number) or your 100%-owned FEIN (Federal Employer Identification Number) for tax purposes to the IRS

Tax Structure

• Mark the appropriate box for tax structure using the following as a guide

• • Individual providers-Must use their SSN if FEIN not 100%-owned

  • Sole Proprietors- May use their SSN or FEIN

  • Corporation-Must use their FEIN

  • Limited Liability Corporation-Must use their FEIN

   

Tax Effective Date

• This date is prefilled with the requested effective date and is not editable

Tax Exempt

• Tax exemption refers to a monetary exemption which reduces taxable income

• If the provider falls under tax exemption status  populate this field, otherwise, leave blank

FEIN

• Federal Employer Identification Number

• Complete this field with the provider’s FEIN if this is their tax reporting type

Social Security Number

• Complete this field with the provider’s SSN if this is their tax reporting type. If the provider is an Individual provider, they must provide their SSN if FEIN not 100%-owned

Does SSN Card state “Not Valid for Employment?”

• Indicate if the provider’s SSN card states “Not Valid for Employment.” If it does, select “Yes;” otherwise, select “No”

• If the Social Security Card states “Not Valid for Employment,” the applicant is not eligible to be a Medicaid provider

DHS/INS Valid for Work Only?

• Department of Homeland Security (DHS) Immigration and Naturalization Service (INS)

• Indicate by populating the checkbox if the Social Security Card states “Valid for work only with DHS/INS authorization.”  If not, then leave this field blank

• Depending on the reason the applicant is in the U.S. will determine the documentation needed. If the applicant has a Social Security Card that states “Valid for work only with DHS/INS authorization,” submit one of the following in the Document Upload screen:

• • DS-2019

  • I-129

  • I-20

  • Work Authorization Card

  • Permanent Resident Card

If an extension has been applied for one of the above documents, upload a copy of the DHS/INS Receipt Notice in Document Uploads

• If the applicant has received a Naturalization Certificate, a permanent Social Security Card must be submitted within 60 days through Maintenance after being approved as a Medicaid provider

DHS/INS Effective Date

• Indicate the DHS/INS effective date if valid for work only with DHS/INS authorization

DHS/INS End Date

• Indicate the DHS/INS end date if valid for work only with DHS/INS authorization

• Enter the end date from one of the applicable DHS/INS documents above

Special Characters:

• The following Special Characters cannot be used in the situations below. Field properties will not allow the following characters in the box:

 For First Name, Business Name, Other name (if any):    | + \ '

 For Last Name field:    | + \ ', and numbers are not allowed

 For Comment Boxes:     <  >  ^  ~ ` + | \ / ¬ £

 For Address fields:    | + ! @ # $ ^ * ( ) ? / \ " < > & : ; _

• If you copy and paste an excluded special character, an error message will display after clicking Save & Next

• Remove excluded characters from pasted information or uploaded text in the document

Save & Next:

• When finished, click Save & Next to save the information and proceed to the next page

• Click Back to go to the previous screen without saving

• Click Exit to return to the dashboard without saving

• Note that if the information is not saved, you will lose the data on the current page