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How to use or fill out Application for Non-Physician Health Care Practitioner with our platform
- Click ‘Get Form’ to open the Application for Non-Physician Health Care Practitioner in the editor.
- Begin by filling out your personal information, including your last name, first name, middle initial, and individual NPI number. Ensure that all required fields are completed accurately.
- Indicate whether this application is due to the COVID-19 pandemic and select the type of application you are submitting (e.g., First-time application, Demographic change).
- Provide your license number and state, Medicare number, and any additional required identifiers such as DEA Certificate number.
- Fill in your primary office address with complete street-level information. Remember that PO Box addresses are not acceptable.
- Complete the correspondence, remittance, and medical record addresses as required. Each must be a valid mailing address.
- Review all entered information for accuracy before signing the applicant attestation section at the bottom of the form.
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