Get Trillium Health Resources Request To Add Licensed Practitioner 2020-2025

This guide provides a detailed walkthrough of the Trillium Health Resources Request To Add Licensed Practitioner form. Following these instructions will help you navigate the online form with confidence and ensure all necessary information is accurately submitted.

Follow the steps to successfully complete the request form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the provider information section. Include the provider's name, date of request, street address, county, city, state, zip code, and phone number.
3. Proceed to the practitioner information section. Here, enter the practitioner's name, license type, email, license number, NPI number, and taxonomy number. Indicate whether the practitioner is currently credentialed with Trillium by selecting 'Yes' or 'No'.
4. Next, address the NC Tracks update question by stating if NC Tracks is updated with locations and affiliations. Choose 'Yes' or 'No' accordingly.
5. In the person submitting request section, fill out the name of the individual submitting the request, their contact information, email, and position.
6. List all service locations where services will be provided. Ensure these addresses are registered in NC Tracks for both the practitioner and the provider. You may enter multiple addresses as needed.
7. Sign and date the form in the signature and date fields.
8. Once the form is completed, review all entered information for accuracy. Save changes, download, and/or print the form as needed.
9. Submit the completed form by email to Credentialing@TrilliumNC.org.

Complete your Trillium Health Resources Request To Add Licensed Practitioner form online today!