Provider recredentialing 2014 form-2025

1. Click ‘Get Form’ to open the provider recredentialing 2014 form in the editor.
2. Begin with Section 1: Demographic Data. Fill in your *Provider Name* and select the type of facility from the provided options, ensuring you check only one box.
3. In Section 2, provide your Professional ID and attach required documents. Ensure you include any necessary accreditations and CMS/Medicare documents relevant to your facility type.
4. Proceed to Section 3: Address Data. Enter your primary address details, including street address, city, state, zip code, and primary telephone number. Make sure to indicate accessibility options.
5. Complete Section 4 regarding Facility Ownership and Staffing by answering questions about ownership and providing details about your Medical Director.
6. Finally, review Section 5 for Application Attachments/Checklist to ensure all required documents are included before signing in Section 6.

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