Practitioner Application Form - Coventry Health Care of KS Inc 2026

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The document is a Practitioner Application Form that outlines the requirements and instructions for healthcare providers applying to participate in a network. It includes sections for personal information, office details, education and training history, work history, licensure, insurance information, and disclosures regarding ownership and control interests. The form requires various supporting documents to be attached and emphasizes the importance of accuracy in the provided information.

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Click ‘Get Form’ to open it in the editor.
Begin with the 'General Information' section. Fill in your CAQH Number, name, birth date, and Social Security Number. Ensure all fields are completed accurately.
Proceed to the 'Primary Office Information' section. Provide details about your practice type, office name, address, and contact information. If applicable, indicate if you treat work-related injuries.
Complete the 'Education and Training' section by listing your medical school and residency details. Attach your Curriculum Vitae if preferred.
In the 'Licensure' section, list all active licenses and DEA numbers for each state where you practice.
Finally, review the 'Provider Attestation' section. Sign and date the form to confirm that all information is accurate before submitting.

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Versions	Form popularity	Fillable & printable
2013	4.8 Satisfied (186 Votes)

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