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Irs pubirs-tegeHealth Care Provider Reference Guide - IRS tax forms 2025

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The document is an application form for non-physician health care practitioners seeking participation with the Excellus Health Plan. It outlines the required documentation, including diplomas, licenses, malpractice insurance, and W-9 forms. The application can be for first-time enrollment or changes in demographics or sponsorship, with specific provisions for temporary participation during the COVID-19 pandemic. It includes sections for personal information, collaborating physician details, and various addresses related to practice. The document emphasizes the need for accurate information and proper attestations from both the applicant and collaborating physician.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out your personal information, including your last name, first name, middle initial, date of birth, gender, and social security number. Ensure accuracy as this information is crucial for processing.
Indicate whether this is a first-time application or a demographic/sponsor change. If applicable, check the box for temporary participation during the COVID-19 Pandemic.
Complete the sections regarding your professional qualifications by selecting your role (e.g., Nurse Practitioner, Physician Assistant) and providing necessary license details such as License # and DEA Certificate #.
Fill in your primary address and ensure it meets postal requirements. Include phone and fax numbers where indicated.
Review the applicant attestation section carefully before signing. This confirms that all provided information is accurate.

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TG 3-8 addresses the concepts of inurement and private benefit pertaining to Section 501(c)(3) organizations. Organizations exempt under Section 501(c)(3) of the Internal Revenue Code (Code) must avoid engaging in impermissible conduct, including that which results in private benefit and inurement.

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