PROVIDER INFORMATION SHEET - McLaren Health Care - mclarenhealthplan 2026

1. Click ‘Get Form’ to open the PROVIDER INFORMATION SHEET in the editor.
2. Begin by filling in your CAQH number and indicate if you are board certified. Specify your board-certified specialty if applicable.
3. Enter your personal details including last name, first name, practice/group name, employer name (if applicable), federal tax ID number, license number, and social security number.
4. Provide your primary office address along with contact details such as telephone and fax numbers. Repeat this for any secondary office addresses.
5. Select your medical specialty from the provided list and indicate whether you are accepting new patients.
6. List your hospital affiliations where you have admitting privileges, marking them as active or other as necessary.
7. Complete the office contact person section with relevant details for follow-up inquiries.
8. Review the provider certification section carefully before signing and dating the document.

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