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How to use or fill out CCRI Enrollment Short Form - Westmoreland County with DocHub
- Click ‘Get Form’ to open the CCRI Enrollment Short Form in our editor.
- In the 'Action Requested' section, enter the effective date of enrollment and your 13-digit PROMISe™ provider ID number.
- For the 'Enrollee’s Name', provide the applicant's name and date of birth. If using a fictitious business name, attach the necessary documentation.
- Fill in the 'Provider Type Number and Description' with the relevant details for your enrollment request.
- Complete the 'Provider Specialty Number and Description' fields as applicable to your services.
- Enter your professional or state license number in the designated field if required.
- List the physical service location where services will be provided, ensuring it is not a P.O. Box.
- Indicate where you want correspondence sent in the 'Mail to Information' section.
- Sign and date the application, print your name, and provide your telephone number. Ensure that you use black ink for signing.
Start filling out your CCRI Enrollment Short Form today using our platform for free!
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See more CCRI Enrollment Short Form - Westmoreland County versions
| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2019 | 4.5 Satisfied (51 Votes) |
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