Get Provider Credentailing Ust Form

Filling out the Provider Credentialing Ust Form online can be a straightforward process when approached step-by-step. This guide provides detailed instructions to help users accurately complete the form while ensuring all necessary information is included.

Follow the steps to complete the Provider Credentialing Ust Form effectively.

1. Click the ‘Get Form’ button to access the Provider Credentialing Ust Form and open it in an editable format.
2. Begin by entering the corporate name as assigned on the W9 in the general information section. Include the Federal Tax Identification Number and the NPI Number.
3. Indicate whether the facility is owned in whole or in part by a hospital system by selecting 'Yes' or 'No' and provide the name of the hospital system if applicable.
4. Select the organizational provider type by checking the relevant box for your facility type, such as Ambulatory Surgery Center, Hospice, or other specified types.
5. Proceed to fill out the demographic and location information. Choose the appropriate address type (Primary Office or Mailing), and complete all fields including the facility’s name, address, city, state, and contact information.
6. In the payment and billing information section, provide the reporting name, corporate name, tax ID number, and billing contact details. Upload a copy of the W-9 IRS form if required.
7. Complete the licensure, certification, and accreditation section by entering the state license number, expiration date, and Medicare/Medicaid participation status. Include any required documentation.
8. Fill in the liability insurance details, including the insurance carrier and policy number, as well as coverage amounts. Attach any relevant copies of insurance documentation.
9. Provide information about ownership and management personnel, including names, titles, and contact details for key individuals associated with the facility.
10. Complete the attestation questionnaire by responding to each question regarding legal actions, licensure, and exclusion status. Provide additional detail on a separate sheet for any 'Yes' responses.
11. Indicate whether the facility validates the credentials for licensed practitioners and specify how the process is conducted.
12. Certify the exclusion certification by confirming checks against the OIG and GSA exclusion lists, and provide the authorized signature along with the date.
13. Finally, complete the release of information and authorization section by signing, dating, and printing your name and title.
14. Once you have filled out the entire form, ensure to save your changes, and then download, print, or share the form as necessary.

Complete your Provider Credentialing Ust Form online today to ensure your organization's compliance.