Use our provider onboarding tools and resources 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'General Information' section. Enter your Corporate Name, Federal Tax Identification Number, and NPI Number. Ensure that the Effective Date is formatted as mm/dd/yyyy.
3. Indicate whether the facility is owned in whole or part by a hospital system by selecting 'Yes' or 'No'. If applicable, specify the Hospital System name.
4. In the 'Organizational Provider Type' section, select all relevant types of services your facility provides. This includes options like Ambulatory Surgery Center, Home Health, and more.
5. Complete the 'Demographic/Location Information' section by providing details for up to three addresses. Specify if each address is a Primary Office or Mailing address and include contact information.
6. Fill out the 'Payment/Billing Information' with your Reporting Name, Corporate Name, Tax ID Number, and Billing Contact details.
7. Provide necessary Licensure/Certification/Accreditation details including State License Number and Medicare/Medicaid participation status.
8. Complete the 'Liability Insurance' section with your Insurance Carrier details and attach a copy of your current insurance policy.
9. Answer questions in the 'Attestation Questionnaire', providing additional details on a separate sheet if any questions are answered ‘Yes’.
10. Finally, review all sections for accuracy before submitting your application through our platform.

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