Get Ks Hca Midwest Health System Division Provider Information Form 2018-2025

Completing the KS HCA Midwest Health System Division Provider Information Form is an essential step for healthcare providers seeking to work with HCA Midwest Division facilities. This guide provides straightforward instructions to help users navigate the online form accurately.

Follow the steps to successfully fill out your provider information form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out your personal information. This includes your name, degree, provider email address, date of birth, Social Security number (SSN), and National Provider Identifier (NPI). Ensure that all fields marked with an asterisk (*) are accurately completed.
3. Next, indicate your employment status. Answer whether you are employed with HCA Physician Services or a locum provider by selecting 'Yes' or 'No' as appropriate. If applicable, provide the PSG start date and specify if you are in telemedicine.
4. Move on to provide your credentialing addresses. You must enter your home address, credentialing address, and primary address. Include all relevant phone numbers and fax numbers.
5. Proceed to the board certification section. State whether you are board certified, and if so, indicate your specialties. If not, you may need to fill out information regarding board eligibility.
6. If you are currently in residency or fellowship, specify the dates of completion and whether this is required for the privileges you are requesting.
7. Complete the facility category section by checkmarking all the facilities you are applying to. Only select those facilities where you are not already a staff member.
8. Lastly, add your signature and date, confirming the completion of the form. If you are using a delegate, ensure you attach the Provider’s Authorization for Delegate form.
9. Once all sections are complete, save your changes. You may then choose to download, print, or share the form as needed.

Complete your documentation online and ensure prompt processing of your request.