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Healthchoices health suppplemental services 2026
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- Click ‘Get Form’ to open the HealthChoices Behavioral Health Supplemental Services Provider Enrollment Application in the editor.
- Begin by checking the type of supplemental service(s) you are applying for in Section 1. Ensure you attach the required documents such as your License or Certificate of Compliance.
- In Section 2, indicate the age group(s) of consumers you will serve by checking the appropriate box(es). This helps clarify your target demographic.
- For Section 3, select the action requested: Initial Enrollment, Revalidation, Service Location Change, or Fee Assignment. Make sure to complete all relevant sections based on your selection.
- Fill out Sections 4 through 19 with accurate information about the enrollee’s name, Tax Identification Information (TIN), National Provider Identifier (NPI), and business type. Remember to use black ink if filling out manually.
- Review all entries for accuracy and legibility before signing and dating the application in Section 19. Ensure that all required attachments are included before submission.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2014 | 4.8 Satisfied (125 Votes) |
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