Data form gateway pdf 2025

1. Click ‘Get Form’ to open the Provider Data Form in the editor.
2. Begin by entering the date at the top of the form. This is essential for tracking your application.
3. Fill in your primary practice state and indicate whether you wish to participate with Medicaid or Medicare by checking the appropriate box and providing your number and effective date.
4. Complete your personal information, including last name, first name, middle initial, primary telephone number, and fax number.
5. Provide your credentialing address and primary address details, including street address, suite number (if applicable), city, state, county, and zip code.
6. Indicate your provider type (e.g., MD, DO) and enter your NPI number. Answer whether you are registered with CAQH and provide your CAQH Provider ID if applicable.
7. Fill out additional fields such as social security number, date of birth, state license number, licensed state, and specialty. Indicate if you are board certified.
8. Select how you are applying (PCP, Specialist, Allied Health Professional) before reviewing all entered information for accuracy.
9. Once completed, save the document and fax it to 1-855-322-2026 as instructed.

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