Get the up-to-date filler promise provider enrollment base application 2011 form-2024 now

Get Form
oltl provider enrollment Preview on Page 1

Here's how it works

01. Edit your pa promise enrollment online
01. Edit your form online
Type text, add images, blackout confidential details, add comments, highlights and more.
02. Sign it in a few clicks
02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
03. Share your form with others
Send it via email, link, or fax. You can also download it, export it or print it out.

The best way to change Filler promise provider enrollment base application 2011 form online

Form edit decoration
9.5
Ease of Setup
DocHub User Ratings on G2
9.0
Ease of Use
DocHub User Ratings on G2

With DocHub, making adjustments to your documentation requires only a few simple clicks. Make these fast steps to change the PDF Filler promise provider enrollment base application 2011 form online free of charge:

  1. Sign up and log in to your account. Log in to the editor with your credentials or click Create free account to evaluate the tool’s features.
  2. Add the Filler promise provider enrollment base application 2011 form for redacting. Click the New Document option above, then drag and drop the sample to the upload area, import it from the cloud, or via a link.
  3. Alter your template. Make any adjustments needed: insert text and photos to your Filler promise provider enrollment base application 2011 form, highlight information that matters, remove parts of content and substitute them with new ones, and add icons, checkmarks, and areas for filling out.
  4. Finish redacting the form. Save the updated document on your device, export it to the cloud, print it right from the editor, or share it with all the people involved.

Our editor is super user-friendly and effective. Try it out now!

See more filler promise provider enrollment base application 2011 form versions

We've got more versions of the filler promise provider enrollment base application 2011 form form. Select the right filler promise provider enrollment base application 2011 form version from the list and start editing it straight away!
Versions Form popularity Fillable & printable
2014 4.9 Satisfied (392 Votes)
2011 4 Satisfied (39 Votes)
be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.
Contact us
Q: WHAT IS THE PROMISe ID? A: The PROMISe, or Provider Reimbursement and Operations Management Information System, ID is an identification number issued by the Pennsylvania Department of Human Services (Department or DHS).
Generally, the only time a provider can bill a Medicaid recipient for a service is if the service is not covered by Medicaid, the provider informed the consumer of this ahead of time, and the consumer consented to paying for the non\u2010covered service out\u2010of\u2010pocket.
Master Provider Index (MPI) MPI is the central repository of information for every provider that provides services for DHS. The MPI system assigns a unique number (MPI number) to every provider in the system. MPI also stores Service Locations for all providers.
1. Enroll with DHS at the individual and group level for each service location (combination of provider type and physical address) at https://provider.enrollment.dpw.state.pa.us. 2. Ensure that all physical addresses signed up for PROMISe ID are valid addresses with Highmark.
Q: WHAT IS THE PROMISe ID? A: The PROMISe, or Provider Reimbursement and Operations Management Information System, ID is an identification number issued by the Pennsylvania Department of Human Services (Department or DHS).
be ready to get more

Complete this form in 5 minutes or less

Get form

People also ask

This form is used for proof of group health care coverage based on current employment. This information is needed to process your Medicare enrollment application. The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment.
ACCESS CARD INFORMATION: \u27a2 Enclosed is your PA ACCESS Card, a permanent, yellow plastic card issued to each individual who is eligible for Medicaid.
If you have questions regarding your provider numbers, please call 1-800-537-8862, select menu option #1, and follow the prompts to reach an enrollment representative.
CMS 855A. Form Title. Medicare Enrollment Application - Institutional Providers. Revision Date.
Do you need more information or have a question? Please fill out the below form or contact us at 1-844-626-6813 (TTY 1-844-349-8916).

Related links