Healthchoices health suppplemental services 2025

1. Click ‘Get Form’ to open the HealthChoices Behavioral Health Supplemental Services Provider Enrollment Application in the editor.
2. 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.
3. In Section 2, indicate the age group(s) of consumers you will serve by checking the appropriate box(es).
4. For Section 3, select the action requested: Initial Enrollment, Revalidation, Service Location Change, or Fee Assignment. Make sure to complete all relevant fields.
5. Fill out Section 4 with the enrollee’s name and date of birth. If applicable, include a fictitious business name statement.
6. Complete Section 5 with Tax Identification Information. Attach necessary documentation like your Social Security card or IRS documents.
7. Continue filling out Sections 6 through 19 as instructed, ensuring all information is accurate and legible. Use black ink if completing by hand.
8. Finally, review your application for completeness before submitting it to the appropriate BH-MCO along with any additional required forms.

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