Pennsylvania Standard Application - Unison Health Plan Home 2025

1. Click ‘Get Form’ to open the Pennsylvania Standard Application in our editor.
2. Begin by filling out the Personal Information section. Ensure you provide your last name, first name, middle name, and Social Security Number accurately.
3. Complete the Medical Licensure/Registration section by entering your medical license number, issue date, and expiration date. If applicable, include your DEA registration details.
4. Proceed to the Education/Training/Hospital Privileges section. Fill in your educational background and any relevant training or residency information.
5. In the Office Practice Information section, describe your practice type and list any managed care programs you participate in. Be sure to indicate office hours and accessibility options.
6. Review all sections for completeness. If additional space is needed, attach extra sheets as necessary and reference the corresponding questions.
7. Finally, sign the attestation page at the end of the application to confirm that all information is accurate before submitting it through our platform.

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