Get Provider Interest Form - Avmed 2020-2025

Completing the provider interest form for Avmed is an important step for healthcare providers interested in joining the network. This guide will walk you through each section of the form, ensuring you understand what information is required and how to submit it correctly.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the provider interest form and open it in your document editor.
2. Begin filling out the provider information section. This includes your first name, middle initial, last name, degree, tax identification number, and primary office address. Be sure to provide your contact phone number and email address.
3. Indicate the type of provider you are by checking the appropriate box in the provider type/description section. Include details such as whether you are a primary care physician, specialist, or part of a group practice.
4. If applicable, provide your board certification status by indicating whether you are board certified or board eligible. Include your primary hospital affiliation and any electronic health record vendors you utilize.
5. List any other physicians or advanced practice registered nurses (APRNs) or physician assistants (PAs) providing services in your office. Ensure this information is legible.
6. Review the entire form to confirm that all information is complete and accurate. Ensure that you have included your signed W-9 form as required.
7. Once you have completed the form, save your changes. You can choose to download, print, or share the provider interest form as needed for your records.

Take the first step towards joining Avmed by completing the provider interest form online today.