COMPLETED BY 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'COMPLETED BY' section. Enter your name, telephone number, and email address to ensure proper communication.
3. Proceed to Section 1: Provider Information. Fill in the provider's first name, middle initial, last name, degree/title, and social security number. Ensure accuracy as this information is crucial for identification.
4. Continue with gender selection and languages spoken by the provider. Indicate if the provider is board certified and provide details regarding eligibility if not certified.
5. In Section 2: Primary Practice Information, enter practice name and address. Confirm if patients can make appointments at this location and whether it should be included in health plan directories.
6. Complete Sections 3 through 5 with payment information, other provider details, and submission instructions as outlined in the form.

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