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Click ‘Get Form’ to open the INDEPENDENT PROVIDER PACKET in the editor.
Begin by reviewing the Information Page, which outlines the requirements for approving an Independent Provider (IP). Ensure you have all necessary documentation ready.
Fill out the Independent Provider Personal and Professional History form. Include details such as the IP's name, address, and qualifications. Both you and the IP must sign this form.
Complete the Acknowledgement of Terms and Release of Liability form. This requires signatures from both you and your IP to confirm understanding of responsibilities.
If applicable, fill out the Assignment of Benefits form to allow direct payment to your provider. Ensure a W-9 form is also completed by your provider.
Submit all completed forms via fax or mail as instructed. Use our platform’s features to easily manage document submission.

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