Form CMS-10495 Physician Registration

Physician Registration
Data elements collected to register physician covered recipients
DE #
Data Element Name
Description
Physician Identifiers
CMS User ID
1
System generated CMS User ID assigned by EIDM and required for registration in Open Payments.
2

Registering Physician Name

The legal name (first, middle, last, suffix) of the physician. Provide the legal name as listed in the National Plan & Provider Enumeration System (NPPES).

3

Registering Physician NPI (National
Provider Identifier)

Individual NPI for a single physician (and not the NPI of a group of physicians). The National Plan and Provider Enumeration System (NPPES) collects identifying
information on health care providers and assigns each a unique National Provider Identifier (NPI).

4

Registering Physician License Number A valid, official state license number and the state of the physician (covered recipient); provide the "License State and License Number" pairs, if a physician is licensed in
and License State
multiple states.

5

Registering Physician DEA Number

A valid U.S. Drug Enforcement Administration (DEA) number assigned to a health care provider for tracking of prescribed controlled substances.

6

Registering Physician Primary Type

Primary type of medicine practiced by the physician (covered recipient). For the purposes of Open Payments, covered recipient physicians may be any of the following:
Medical Doctor (MD), Doctor of Osteopathy (DO), Doctor of Dentistry (DDS), Doctor of Podiatric Medicine (DPM), Doctor of Optometry (OD), and Chiropractor (DCP).

7

Registering Physician Specialty Code

The physician specialty code of the physician (covered recipient) as listed in the health care provider taxonomy codes list.

8

Registering Physician Email

The primary business email address for the physician (covered recipient),who has received a payment or transfer of value. Provide the preferred email for
communications from Open Payments about the program and information reported by applicable manufacturers and applicable group purchasing organizations.

Physician Practice Identifiers
9
Registering Physician Practice Name

The legal name of the practice or group practice (a single legal entity with two or more physicians legally organized as a partnership, professional corporation,
foundation, not-for-profit-corporation, faculty practice plan, or similar association). Physicians have the option to enter additional practice names.

10

Physician Practice Business Address

The primary business (or practice location) address (Number and Street (or PO Box), City, State, and 9-digit Zip Code) of the physician (covered recipient), who has
received payments or transfers of value. For international addresses, also provide the Province, Country and International Postal Code, if applicable. Physicians have the
option to enter addition practice business addresses.

11

Registering Physician Practice Phone
Number

The primary business phone number for the physician (covered recipient),who has received a payment or transfer of value. Provide the preferred phone number for
communications from Open Payments about the program and information reported by applicable manufacturers and applicable group purchasing organizations about
the covered recipient.

Physician Authorized Representative Identifiers
12
Registering Physician Authorized
Legal name (first, middle, last, suffix) of an individual authorized by the physician (covered recipient) to access/review data and initiate a dispute on behalf of the
Representative Name
physician.
13

Registering Physician Authorized
Representative Job Title

The official title of the job or position held by the individual or employee of the physician practice authorized by the physician to access and review the physician's data or
initiate a dispute in Open Payments.

14

Registering Physician Authorized
Representative Email Address

The primary business email address for the individual or employee of the physician practice authorized by the physician to access/review data and initiate a dispute on
behalf of the physician in Open Payments.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW

1

Physician Registration
15

Registering Physician Authorized
Representative Phone Number

The primary business phone number for the individual or employee of the physician practice authorized by the physician to access/review data and initiate a dispute on
behalf of the physician.

16

Registering Physician Authorized
Representative Business Address

The primary business address for the individual or employee of the physician practice authorized by the physician to access/review data and initiate a dispute on behalf
of the physician.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW

2