Form CMS-10114, NPI Application/Update Completed Form Examples and Samples
Explore a detailed example of a completed CMS-10114 NPI Application form for new healthcare providers. This guide provides insights into filling out the form accurately with sample entries from Dr. Jane Smith, a General Practitioner. Learn how to correctly complete provider sections, contact information, and more.
NPI Application Example – New Provider
How this form was filled:
This example illustrates a completed CMS-10114 form for a new healthcare provider applying for a National Provider Identifier (NPI). Dr. Jane Smith's details are included, demonstrating correct entry for individual provider applications. The form is signed electronically and dated in the current year.
Information used to fill out the document:
- Provider’s Full Name: Dr. Jane Smith
- Provider Type: Individual
- Specialization: General Practitioner
- SSN: 123-45-6789
- Practice Address: 789 Health St, Wellness City, USA
- Phone Number: 555-0123
- Email: [email protected]
- Electronic Signature: Dr. Jane Smith
- Date of Submission: 03/05/2025
What this filled form sample shows:
- Detailed provider name and type sections
- Accurate practice address and contact information
- Correctly filled specialization and taxonomy fields
- Proper electronic signature and current date
Form specifications and details:
| Use Case: | New healthcare provider applying for NPI |
| Form Name: | CMS-10114 |
