Get Connecticare Practitioner Data Form - Ynhh

Filling out the ConnectiCare Practitioner Data Form online is a crucial step in the credentialing process for providers. This guide offers clear, step-by-step instructions to help users confidently complete the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Begin by entering the date at the top of the form. This helps to track when your application is submitted.
3. Provide your first name, last name, and middle initial in the designated fields to ensure correct identification.
4. Select your title from the available options. If you are a midlevel provider, specify your supervisor or collaborating physician's name.
5. Indicate whether you are accepting new patients by selecting 'Yes', 'No', or 'N/A.' If you select 'Yes', provide the name of the board you are certified with.
6. Fill in your date of birth, social security number, and gender selection.
7. Input your licensed state, license number, Federal DEA number, National Provider Identifier (NPI) number, and Tax ID number in the corresponding fields.
8. Answer whether you practice exclusively in an inpatient setting. If yes, provide the hospital name.
9. Specify your working hours per week and your specialty.
10. Complete your primary practice location, including street address, city, state, and zip code. Indicate whether the location is wheelchair accessible.
11. Fill out the payment address and mailing address, ensuring all information is accurate.
12. Provide the credentialing contact name, direct phone number, and email address for communication purposes.
13. Review all the information for accuracy before finalizing your application.
14. Once completed, save your changes, and utilize the options to download, print, or share the form as necessary.

Complete your ConnectiCare Practitioner Data Form online today and ensure a smooth credentialing process.