Ambulatory Surgery Center Network Provider Contract - ok 2025

1. Click ‘Get Form’ to open the Ambulatory Surgery Center Network Provider Contract in the editor.
2. Begin by filling out the 'General Information' section, including the legal name of the owner and trade name. Ensure all fields are completed accurately.
3. Provide your facility's license information, including state, license number, and expiration date. Attach a copy of the facility license as required.
4. Complete the 'Accreditation' section by indicating if your facility is accredited by relevant organizations like the Joint Commission or AAAHC, and provide necessary details.
5. Fill in the insurance information with details about your current general and medical liability insurance coverage. Attach a copy of the insurance certificate.
6. Enter important facility contacts for CEO/Administrator and contracting/managed care personnel, ensuring to include phone numbers and email addresses.
7. Complete all address sections: physical address (for services), mailing address (for correspondence), and billing address (for claims).
8. Review all entered information for accuracy before submitting. Use our platform’s features to save or print a copy for your records.

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