Get Provider Participation Request Form - Coventry Health Care

This guide provides a detailed overview of how to accurately fill out the Provider Participation Request Form for Coventry Health Care. Whether you are an individual practitioner or representing a facility, the following steps will assist you in completing the form online with ease.

Follow the steps to successfully complete your request form.

1. Click the ‘Get Form’ button to access the Provider Participation Request Form. Ensure you have a reliable internet connection to smoothly open the document in your preferred editor.
2. Begin by indicating whether you are a ‘Practitioner’ or a ‘Facility/Ancillary’ provider at the top of the form. This will help determine which fields are applicable to you. Any fields not relevant to your provider type should be marked as ‘N/A’.
3. In the Provider Information section, fill in your name, date of birth, office/facility name, and complete the address details. Make sure to include your office phone number, email, and office contact person’s information.
4. Continue filling out the additional provider details, such as your NPI number, gender, specialty, and hospital privileges. Ensure all information is accurate and up-to-date.
5. In the Billing Information section, provide the group/practice name and tax ID. Attach a copy of your W9 form as instructed. Additionally, complete the contact person and billing address details.
6. Answer the Yes/No questions regarding your practice settings and whether you accept new Workers' Compensation cases. This information is crucial for your participation request.
7. Proceed to the section that must be completed by the provider, where you indicate your desired participation type and any additional designations. If applicable, list any covering physicians in your practice.
8. Once you have filled out all the necessary sections, review your entries to ensure all data is correct and complete. Pay special attention to required fields.
9. Finally, save your changes, and download or print the completed form for your records. You may share the form as needed with relevant parties involved in your provider participation process.

Begin your application process online by filling out the Provider Participation Request Form today.