Magellan interested provider information form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your Individual or Group MIS# at the top of the form. This is essential for identification within Magellan's system.
3. 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.
4. Complete the License Type and License# fields. If applicable, include your Medicaid ID# and NPI# (Type 1).
5. Fill out your mailing address and primary practice address accurately. This ensures that all correspondence reaches you without delay.
6. If you are a group member, indicate the Group Name and answer whether you have been employed by Magellan before.
7. In Section II, if applicable, provide details about your Group/Organization including NPI (Type 2) and contact information.
8. 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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