Get Network Advantage Provider Application Form
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How to fill out the Network Advantage Provider Application Form online
Filling out the Network Advantage Provider Application Form online is a critical step for individuals looking to become EAP/Behavioral Health Providers. This guide provides clear and detailed instructions to ensure your application is complete and accurate.
Follow the steps to successfully complete the application form.
- Click ‘Get Form’ button to access the Network Advantage Provider Application Form and open it for completion.
- Begin filling out the 'Provider Information' section. Provide your first name, middle name, last name, social security number, date of birth, gender, national provider identifier, years in practice, and post-master’s clinical experience.
- In the 'Licensure' section, list all current licenses and certifications. Ensure to include the class of your current license, license type, license number, and expiration date.
- Complete the 'Certifications' section by providing details of any additional certifications, including state or national, along with their license numbers and expiration dates where applicable.
- Fill in the 'Office Information’ with practice type, address, secure contact details, and operational hours for each day of the week.
- Provide your 'Current Professional Liability Insurance Information,' including the name of the carrier, policy number, effective date, and limits of coverage.
- In the 'Education and Training' section, indicate your highest degree attained and details about your graduate or medical school.
- For 'Hospital Privileges', list each hospital where privileges are extended, including contact details and type of privileges.
- Answer the questions in the 'Disclosure' section truthfully. If responding 'yes' to any inquiries, provide detailed explanations as required.
- Review the 'Authorization, Attestation and Release' section. After confirming all information is accurate, provide your printed name, signature, and the date.
- Save your changes, and utilize options to download, print, or share your completed application form as needed.
Complete your application online today to join the Network Advantage Provider network.
Provider enrollment is the process where healthcare providers register with insurance companies or government programs to qualify for payment for their services. This process typically involves verifying credentials, completing the appropriate forms, and ensuring compliance with regulations. Using the Network Advantage Provider Application Form simplifies this process, helping providers gain quicker access to reimbursement.
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