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Get Amerigroup Disclosure Form
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How to fill out the Amerigroup Disclosure Form online
Filling out the Amerigroup Disclosure Form is an essential step for individuals seeking network participation as a Provider Person. This guide provides clear and user-friendly instructions to help you complete the form accurately and efficiently.
Follow the steps to complete the Amerigroup Disclosure Form online.
- Click the ‘Get Form’ button to obtain the form and open it in your preferred document editor.
- In the Identifying Information section, enter your full name, Social Security Number, date of birth, home address, NPI number, and Medicaid ID number. Ensure all details are correct as they will be used for validation.
- Provide information about the Provider Entity you are associated with, including the entity name, TIN, DBA, and address. If you have multiple practice locations, list all of them.
- In the Criminal Offense Attestation section, answer all questions regarding convictions, debarments, exclusions, and terminations related to Medicaid or Medicare programs. If applicable, provide the required details such as names, dates, and reasons for each circumstance.
- For Sole Proprietors, complete the questions related to managing employees and agents. Include their names, SSNs, and details about any criminal offenses they may have encountered.
- Ensure that all sections and questions are thoroughly answered. If a question is not applicable, write N/A. Do not leave any questions blank, and note any continuation on a separate sheet if necessary.
- Review all information entered to confirm accuracy. Once completed, print the form for signature.
- Sign the form as the Provider Person, enter the date, and provide your phone number for further contact. Ensure that the form is signed appropriately to avoid complications.
- Save the changes made to the form, and keep a copy for your records. You can then either download, print, or share the completed form as required.
Complete the Amerigroup Disclosure Form online today to ensure your application is processed smoothly.
Yes, Amerigroup is a key provider of Medicaid services in Tennessee, supporting members with various health needs. Their focus is on providing quality care and improving health outcomes for enrolled individuals. Completing the Amerigroup Disclosure Form will help ensure you understand the various services and programs available under Tennessee Medicaid.
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