Become a Participating ProviderProvidersExcellus ...Nonphysician Health Care Professionals Billing Evaluation ...Nonphysician Health Care Professionals Billing Evaluation ...FREE 11+ Health Care Application Forms in PDFMs Word ... 2025

1. Click ‘Get Form’ to open the application in the editor.
2. Begin by filling out your personal information, including your last name, first name, middle initial, gender, date of birth, and social security number. Ensure accuracy as this information is crucial for processing.
3. Indicate whether this is a first-time application or if you are applying due to a demographic or sponsor change. Select your professional designation from the options provided.
4. Complete the sections for your licenses and certifications, including your individual NPI number, license number, DEA certificate details, and Medicare/Medicaid numbers if applicable.
5. Proceed to fill out the address section. Provide complete street-level addresses for primary, remittance, correspondence, and medical record locations. Remember that PO Box addresses are not accepted without corresponding city and state information.
6. Review the applicant attestation section carefully before signing. Ensure all information is accurate and complete.
7. Finally, submit your completed application along with required documents via email or fax as indicated in the instructions.

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