URGENT CARE CENTER MEDICAL AID UNIT (MAU) & RETAIL CLINIC APPLICATION 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'General Information' section. Enter the Legal Name, DBA Name, and provide your Federal Tax ID Number, National Provider Identifier Number, and State License/Registration/Certification Number if applicable.
3. Complete the 'Provider Type' section by selecting the appropriate option for your application. Indicate whether you are a Hospital Based/Owned/Affiliated or Free Standing facility.
4. In the 'Contacts' section, provide details for the Application Contact Name, Title, Phone Number, and Email. Ensure all information is accurate for effective communication.
5. Fill out the 'Electronic Connectivity Contact Information' with relevant details such as NaviNet and EFT Contact Name along with their phone numbers and emails.
6. Review the 'Materials Checklist' to ensure you have attached all necessary documents like licenses and certifications before submission.
7. Finally, sign and date the application at the bottom of the form to confirm that all information provided is true and complete.

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