Data collection form no download needed 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Provider Name' and 'Provider ID or application tracking number (ATN)' in the designated fields.
3. Fill in the primary user's details, including their last name, first name, middle initial, and date of birth in MMDD format.
4. Create a unique four-digit PIN as required. Ensure this is memorable yet secure.
5. Provide the work zip code, work email address, existing Virtual Gateway user ID (if applicable), and contact phone number.
6. Select your status by checking one of the options: MassHealth provider, provider applicant, or other types listed.
7. Review the certification statement carefully before signing. Ensure all information is accurate and complete.
8. Finally, submit the completed form via email or fax as instructed at the bottom of the document.

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