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Magellan interested provider information form 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling in your Individual or Group MIS# at the top of the form. This is essential for identification within Magellan's system.
- In Section I, provide your personal details including Last Name, First Name, Date of Birth, and Gender. Ensure accuracy as this information is crucial for processing.
- Complete the License Type and License# fields. If applicable, include your Medicaid ID# and NPI# (Type 1).
- Fill out your mailing address and primary practice address accurately. This ensures that all correspondence reaches you without delay.
- If you are a group member, indicate the Group Name and answer whether you have been employed by Magellan before.
- In Section II, if applicable, provide details about your Group/Organization including NPI (Type 2) and contact information.
- Finally, review all sections for completeness before submitting the form along with a completed W9 via fax to ensure prompt processing.
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