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{"sheet":"Instruction Form","index":0,"n_rows":60,"n_cols":2,"rows_kept":60,"cut":false,"hidden":false,"merged":[[59,0,59,9],[30,0,30,9],[24,1,24,9],[23,1,23,9],[22,1,22,9],[21,1,21,9],[18,1,18,9],[2,0,2,9],[6,1,6,9],[11,1,11,9],[12,1,12,9],[3,0,3,9],[13,1,13,9],[14,1,14,9],[15,1,15,9],[19,1,19,9],[20,1,20,9],[8,1,8,9]]}
[]
[]
["Provider Profile Information Form (PPIF)"]
["Instruction Form and Claims Reference Guide"]
[]
["General Instructions"]
[null,"1.  For faster processing, complete this PPIF in Excel and submit the Excel file via email."]
[]
[null,"2.  Complete one PPIF per entity (TIN).  If you plan to file claims under multiple entities (TINs), submit one PPIF for each TIN."]
[]
["Page 1 – Business Entity Information"]
[null,"Legal name of Entity – Legal name of Contractor as filed per federal W9"]
[null,"Description of Legal Entity –Please select appropriate description.  If your entity type is not listed, please select ‘Other’ and state the appropriate entity type. "]
[null,"Contract Notice Party – Contact information of person authorized to receive legal notices per contract requirements"]
[null,"Business Contact – Contact information of person authorized to represent Contractor’s administrative interests "]
[null,"Medicare, Medi-Cal and Federal Exclusions – Must be checked either YES or NO."]
[]
["Page 2 – Payment Information"]
[null,"Full Roster (vs) Update: Check Full Roster or Update in this section."]
[null,"Full Roster: Check this box (x) when submitting a complete list of Contracted entity’s care Locations and or Practitioners. List only the care locations and practitioners that are intended to be associated with the contract. "]
[null,"Update:  Check this box (x) when submitting this form for additions or revisions to billing, care Location and Practitioner information. State the reason for update in the comments section. "]
[null,"Billing - Enter TAX ID Number (TIN), Legal Name, Doing Business As (if applicable) and Corporate Address as filed with IRS. Enter Pay- to address (if different from corporate address). Enter Billing NPI – this is typically the billing provider’s group NPI.  If there are multiple billing provider NPIs, please mark (x) to answer ‘Yes’. Enter contact information of the person who can assist with our questions about the information provided on the form. "]
[null,"Care Location - Complete Boxes A-E for all places of service.  Box A should reflect the Location’s “Doing Business As” (dba) name, if different than the legal name reported on Page 1.  The row number/s in the Care Locations section (L1, etc) should be used to reference the location/s where Practitioners (individually identified on Page 2) render services, as applicable. Otherwise, use this section to identify individual locations rendering facility/agency services to members and complete Box F, California License Number of Location."]
[null,"Credentialing Contact - (For Organizational Providers i.e. facilities/agencies only)-  Provide contact information of person authorized to submit credentialing documents on behalf of each Location and assist with the coordination of site surveys, as applicable. For professional Providers, practitioners are still personally required to complete their credentialing application if offering services through a professional agreement."]
[null,"Comments – Please use this section to provide the reason for submitting PPIF.  Any additional information regarding the data on PPIF can also be stated here. Please see some examples below:"]
[null,"a. For TIN changes: disclose old TIN and new TIN along with the effective date for the new TIN."]
[null,"b. For relocation: disclose the old Location and new Location address along with the effective date for relocation."]
[null,"Note: If there are specific dates associated with multiple changes on this form, please state here."]
["Page 3 – Additional Locations: Add additional care Locations to supplement page 2."]
[]
["UB - 04 "]
[]
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["Provider Profile Information Form"]

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[null,"PROVIDER PROFILE INFORMATION FORM - ICF",null,null,null,null,null,null,null,null,null,"Page 1"]
[]
["PLEASE SUMMARIZE CHANGES IN THIS SECTION, INCLUDING EFFECTIVE DATE:"]
[]
["Contractor Entity"]
["LEGAL NAME OF ENTITY:                                                                              "]
["LEGAL ENTITY TAX IDENTIFICATION NUMBER:"]
["                                                (as filed on the IRS W-9 form for this Tax Identification Number)  **Please attach a copy of the W-9 Form**"]
["Are there other legal entities that should be a party to this contract? Yes  [      ]   No  [      ]                                                                                                                                              (If \"Yes\", please complete and attach a separate sheet for each legal entity)"]
["Description of Legal Entity"]
[null,null,null,"Type of Entity",null,null,null,"State"]
[null,null,null,"[    ]","Corporation "]
[null,null,null,"[    ]","Professional Corporation"]
[null,null,null,"[    ]","Limited Liability Company"]
[null,null,null,"[    ]","Sole Proprietorship"]
[null,null,null,"[    ]","Other : "]
["Contract Notice Party"]
["Name:"]
["Title:"]
["Address:"]
["City, State, Zip:"]
["Telephone Number:",null,"(      )",null,null,null,"Fax Number","(      )"]
["Email Address:"]
["Contract Signatory Name:",null,null,null,null,null,"Title: "]
["Business Contact"]
["Name:"]
["Title:"]
["Address:"]
["City, State, Zip:"]
["Telephone Number:",null,"(      )",null,null,null,"Fax Number","(      )"]
["Email Address:"]
["Are any Practitioners or Locations excluded from treating Medicare, Medi-Cal, and/or Federal Employees, or on any State or Federal Exclusion, Preclusion, Sanction or Opt Out Lists? (If yes, submit separate sheet with Practitioners or Locations)",null,null,null,null,null,null,"YES",null,"NO"]
["The undersigned attests to the completeness and accuracy of the submitted information.  If the contract between Contractor and Kaiser references the Provider Profile Information Form, this Provider Profile Information Form shall be incorporated into, and made a part of such contract."]
["Name of Submitter:",null,null,null,null,"Date Submitted:"]
["Title of Submitter:",null,null,null,null,"Email Address of Submitter:"]
["Telephone Number:",null,"(      )",null,null,"Fax Number:",null,"(      )"]

{"sheet":"Payment Information","index":2,"n_rows":38,"n_cols":23,"rows_kept":38,"cut":false,"hidden":false,"merged":[[10,18,10,22],[21,16,21,17],[20,16,20,17],[26,16,26,17],[27,16,27,17],[32,16,32,17],[33,16,33,17],[6,0,6,22],[7,0,7,7],[7,8,7,22],[8,0,8,7],[11,0,11,5],[11,12,11,22],[12,0,12,5],[12,12,12,22],[14,0,14,22],[15,0,15,1],[15,3,15,22],[8,8,8,22],[9,0,9,7],[9,8,9,11],[9,12,9,22],[13,0,13,4],[13,5,13,6],[1,0,1,22],[2,0,2,22],[3,0,3,22],[4,0,4,2],[4,17,4,18],[4,19,4,22],[5,0,5,2],[5,17,5,18],[5,19,5,22],[5,3,5,14],[4,3,4,14],[4,15,5,16],[13,9,13,11],[12,6,12,11],[11,6,11,11],[10,0,10,7],[10,8,10,11],[10,13,10,14],[10,15,10,16],[16,0,17,0],[16,1,17,1],[16,2,21,2],[16,3,16,8],[17,3,18,8],[18,0,19,0],[18,1,19,1],[19,3,19,8],[20,0,21,0],[20,1,21,1],[20,3,21,8],[20,9,20,10],[16,9,16,11],[17,9,18,11],[34,0,34,22],[35,0,35,2],[35,3,35,8],[35,9,35,11],[35,12,35,22],[0,1,0,21],[28,3,28,8],[29,3,30,8],[30,0,31,0],[30,1,31,1],[31,3,31,8],[32,0,33,0],[32,1,33,1],[32,3,33,8],[28,9,28,11],[29,9,30,11],[22,0,23,0],[22,1,23,1],[22,2,27,2],[22,3,22,8],[23,3,24,8],[24,0,25,0],[24,1,25,1],[25,3,25,8],[38,0,38,22],[36,0,36,2],[36,3,36,8],[36,9,36,11],[36,12,36,22],[37,0,37,2],[37,3,37,8],[37,9,37,11],[37,12,37,22],[16,18,16,22],[17,18,18,22],[19,9,19,22],[21,9,21,10],[16,15,16,17],[17,15,18,17],[16,12,16,14],[17,12,18,14],[21,12,21,14],[22,12,22,14],[22,15,22,17],[23,12,24,14],[20,12,20,14],[22,9,22,11],[22,18,22,22],[23,9,24,11],[23,18,24,22],[23,15,24,17],[28,0,29,0],[28,1,29,1],[28,2,33,2],[28,18,28,22],[25,9,25,22],[26,9,26,10],[26,12,26,14],[27,9,27,10],[27,12,27,14],[29,18,30,22],[31,9,31,22],[32,9,32,10],[32,12,32,14],[33,9,33,10],[33,12,33,14],[28,12,28,14],[28,15,28,17],[29,12,30,14],[29,15,30,17],[26,0,27,0],[26,1,27,1],[26,3,27,8]]}
[null,"PROVIDER PROFILE INFORMATION FORM - ICF",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Page 2"]
[]
["PLEASE SUMMARIZE CHANGES IN THIS SECTION, INCLUDING EFFECTIVE DATE:"]
[]
["1. Tax ID (TIN):",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2. Check one:",null,"Full Roster "]
["3. Legal Name:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Update"]
["Billing Provider, NPI & Addresses\nBilling Provider, DBA and TIN must match W9, otherwise W9 info will be used. For Electronic Biling, call EDI Helpline at (866) 285-0362."]
["4. 1099 Corporate Address as filed with IRS:",null,null,null,null,null,null,null,"5. Pay to Address  (If different from 1099):"]
[]
["6. Doing Business As (DBA):",null,null,null,null,null,null,null,"7. Billing NPI:",null,null,null,"8. Multiple Billing NPIs:"]
[null,null,null,null,null,null,null,null,null,null,null,null,"Yes:",null,null,"No:"]
["9. Billing Contact Name:",null,null,null,null,null,"10. Billing Contact Email:",null,null,null,null,null,"11. Billing Contact Phone:"]
[]
["12. How will your home submit claims/invoices to Kaiser Permanente?  \n(Please check \"X\" in one box)",null,null,null,null,"Paper UB-04 Claim Form:",null,null,null,"Electronic UB-04 Claim Form: ",null,null,null,null,"Paper Invoice:"]
["Care Locations (Place of Service)\nList additional Care Locations on page 3"]
["Update Type:",null,"Loc#:"]
[null,"Add","L1","A. Doing Business As (dba) Name of Location:",null,null,null,null,null,"B. Location Phone:",null,null,"C. Fax:",null,null,"D. Location NPI:",null,null,"E. CA License Number of Location, if applicable:"]
[]
[null,"Delete"]
[null,null,null,"F. Physical Address:",null,null,null,null,null,"G. Type of home: Please check \"X\" in one box and indicate the total number of beds in the home, regardless of current client census:"]
[null,"Update",null,null,null,null,null,null,null,"ICF-DD:",null,null,"ICF-DD H:",null,null,null,"ICF-DD N:"]
[null,null,null,null,null,null,null,null,null,"Total Bed Capacity:",null,null,"Total Bed Capacity:",null,null,null,"Total Bed Capacity:"]
[null,"Add","L2","A. Doing Business As (dba) Name of Location:",null,null,null,null,null,"B. Location Phone:",null,null,"C. Fax:",null,null,"D. Location NPI:",null,null,"E. CA License Number of Location, if applicable:"]
[]
[null,"Delete"]
[null,null,null,"F. Physical Address:",null,null,null,null,null,"G. Type of home: Please check \"X\" in one box and indicate the total number of beds in the home, regardless of current client census:"]
[null,"Update",null,null,null,null,null,null,null,"ICF-DD:",null,null,"ICF-DD H:",null,null,null,"ICF-DD N:"]
[null,null,null,null,null,null,null,null,null,"Total Bed Capacity:",null,null,"Total Bed Capacity:",null,null,null,"Total Bed Capacity:"]
[null,"Add","L3","A. Doing Business As (dba) Name of Location:",null,null,null,null,null,"B. Location Phone:",null,null,"C. Fax:",null,null,"D. Location NPI:",null,null,"E. CA License Number of Location, if applicable:"]
[]
[null,"Delete"]
[null,null,null,"F. Physical Address:",null,null,null,null,null,"G. Type of home: Please check \"X\" in one box and indicate the total number of beds in the home, regardless of current client census:"]
[null,"Update",null,null,null,null,null,null,null,"ICF-DD:",null,null,"ICF-DD H:",null,null,null,"ICF-DD N:"]
[null,null,null,null,null,null,null,null,null,"Total Bed Capacity:",null,null,"Total Bed Capacity:",null,null,null,"Total Bed Capacity:"]
["Credentialing Contact\nFor Facility Providers, list the local facility contact who can assist with coordination of site visits"]
["14. Contact Name:",null,null,null,null,null,null,null,null,"15. Phone Number:                   "]
["16. Title:",null,null,null,null,null,null,null,null,"17. Fax Number:                "]
["18.  Address:",null,null,null,null,null,null,null,null,"19. Email:"]

{"sheet":"Addl Locations","index":3,"n_rows":26,"n_cols":10,"rows_kept":26,"cut":false,"hidden":false,"merged":[[0,0,0,8]]}
["Care Locations (Place of Service)",null,null,null,null,null,null,null,null,"Page 3"]
["Update Type\n(Add, Delete, Update)","Row ","A. Doing Business As (dba) Name of Location:","D. Physical Address:","B. Phone:","C. Fax:","E. Location NPI","F. CA License Number of Location, if applicable:","G. Type of Home","G1. Total Bed Capacity"]
[{"$f":"IF('Payment Information'!A17<>\"\",\"Add\",IF('Payment Information'!A19<>\"\",\"Delete\",IF('Payment Information'!A21<>\"\",\"Update\",\"\")))","v":""},"L1",{"$f":"IF('Payment Information'!D18=\"\",\"\",'Payment Information'!D18)","v":""},{"$f":"IF('Payment Information'!D21=\"\",\"\",'Payment Information'!D21)","v":""},{"$f":"IF('Payment Information'!J18=\"\",\"\",'Payment Information'!J18)","v":""},{"$f":"IF('Payment Information'!M18=\"\",\"\",'Payment Information'!M18)","v":""},{"$f":"IF('Payment Information'!P18=\"\",\"\",'Payment Information'!P18)","v":""},{"$f":"IF('Payment Information'!S18=\"\",\"\",'Payment Information'!S18)","v":""},{"$f":"IF('Payment Information'!L21<>\"\",\"ICF-DD\",IF('Payment Information'!P21<>\"\",\"ICF-DD H\",IF('Payment Information'!S21<>\"\",\"ICF-DD N\",\"\")))","v":""},{"$f":"IF('Payment Information'!L21<>\"\",'Payment Information'!L22,IF('Payment Information'!P21<>\"\",'Payment Information'!P22,IF('Payment Information'!S21<>\"\",'Payment Information'!S22,\"\")))","v":""}]
[{"$f":"IF('Payment Information'!A23<>\"\",\"Add\",IF('Payment Information'!A25<>\"\",\"Delete\",IF('Payment Information'!A27<>\"\",\"Update\",\"\")))","v":""},"L2",{"$f":"IF('Payment Information'!D24=\"\",\"\",'Payment Information'!D24)","v":""},{"$f":"IF('Payment Information'!D27=\"\",\"\",'Payment Information'!D27)","v":""},{"$f":"IF('Payment Information'!J24=\"\",\"\",'Payment Information'!J24)","v":""},{"$f":"IF('Payment Information'!M24=\"\",\"\",'Payment Information'!M24)","v":""},{"$f":"IF('Payment Information'!P24=\"\",\"\",'Payment Information'!P24)","v":""},{"$f":"IF('Payment Information'!S24=\"\",\"\",'Payment Information'!S24)","v":""},{"$f":"IF('Payment Information'!L27<>\"\",\"ICF-DD\",IF('Payment Information'!P27<>\"\",\"ICF-DD H\",IF('Payment Information'!S27<>\"\",\"ICF-DD N\",\"\")))","v":""},{"$f":"IF('Payment Information'!L27<>\"\",'Payment Information'!L28,IF('Payment Information'!P27<>\"\",'Payment Information'!P28,IF('Payment Information'!S27<>\"\",'Payment Information'!S28,\"\")))","v":""}]
[{"$f":"IF('Payment Information'!A29<>\"\",\"Add\",IF('Payment Information'!A31<>\"\",\"Delete\",IF('Payment Information'!A33<>\"\",\"Update\",\"\")))","v":""},"L3",{"$f":"IF('Payment Information'!D30=\"\",\"\",'Payment Information'!D30)","v":""},{"$f":"IF('Payment Information'!D33=\"\",\"\",'Payment Information'!D33)","v":""},{"$f":"IF('Payment Information'!J30=\"\",\"\",'Payment Information'!J30)","v":""},{"$f":"IF('Payment Information'!M30=\"\",\"\",'Payment Information'!M30)","v":""},{"$f":"IF('Payment Information'!P30=\"\",\"\",'Payment Information'!P30)","v":""},{"$f":"IF('Payment Information'!S30=\"\",\"\",'Payment Information'!S30)","v":""},{"$f":"IF('Payment Information'!L33<>\"\",\"ICF-DD\",IF('Payment Information'!P33<>\"\",\"ICF-DD H\",IF('Payment Information'!S33<>\"\",\"ICF-DD N\",\"\")))","v":""},{"$f":"IF('Payment Information'!L33<>\"\",'Payment Information'!L34,IF('Payment Information'!P33<>\"\",'Payment Information'!P34,IF('Payment Information'!S33<>\"\",'Payment Information'!S34,\"\")))","v":""}]
[null,"L4"]
[null,"L5"]
[null,"L6"]
[null,"L7"]
[null,"L8"]
[null,"L9"]
[null,"L10"]
[null,"L11"]
[null,"L12"]
[null,"L13"]
[null,"L14"]
[null,"L15"]
[null,"L16"]
[null,"L17"]
[null,"L18"]
[null,"L19"]
[null,"L20"]
[null,"L21"]
[null,"L22"]
[null,"L23"]
[null,"L24"]

{"sheet":"CCPA Notice","index":4,"n_rows":0,"n_cols":0,"rows_kept":0,"cut":false,"hidden":false,"merged":[]}

{"sheet":"Sheet1","index":5,"n_rows":4,"n_cols":1,"rows_kept":4,"cut":false,"hidden":true,"merged":[]}
[]
["ICF-DD"]
["ICF-DD H"]
["ICFDD N"]