Guardian-research provider-interest-formPROVIDER INTEREST FORM - Guardian Research 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the PROVIDER INFORMATION section. Enter your first name, middle initial, last name, degree, and date. Ensure that your Tax ID# and NPI are accurately provided.
3. Complete the facility name and primary office address fields. Include your office hours and contact information such as phone number, fax number, and email address.
4. In the PROVIDER TYPE/DESCRIPTION section, check the appropriate box for your practice type (e.g., Primary Care/Specialists). Indicate if you are board certified or eligible.
5. If applicable, provide details about your hospital affiliations and any other physicians or ARNPs/PA's working in your office.
6. Review all entries for accuracy and legibility before submitting the form along with a signed W-9 to ensure compliance with credentialing criteria.

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