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- Click ‘Get Form’ to open the Solo Provider Enrollment Form in the editor.
- Begin by filling out the Submitter Information section. Ensure you complete all required fields marked with an asterisk, including your First Name, Last Name, Email Address, and Telephone Number.
- Proceed to the Practitioner Information section. Here, indicate if you are currently in a residency program and provide your Primary Provider Type and Specialty.
- In the Personal Information section, enter your Date of Birth and Gender. This information is crucial for accurate identification.
- Complete the Office Physical Location section by providing details about your practice location, including Address Line 1, City, State, and Zip Code.
- Review all sections carefully before submitting. Make sure that all required fields are filled out accurately to avoid delays in processing.
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