Get Physician Data Sheet Form - Anthem

Completing the Physician Data Sheet Form - Anthem is a crucial step in the credentialing process for healthcare providers. This guide provides clear, step-by-step instructions for successfully filling out the form online, ensuring that you provide all necessary information accurately.

Follow the steps to complete your Physician Data Sheet Form - Anthem online.

1. Click ‘Get Form’ button to obtain the Physician Data Sheet Form - Anthem and open it in your preferred editor.
2. Begin with Part I of the form. Indicate the line of business for which you are applying for credentialing by circling all that apply: PPO, HMO.
3. Fill in your last name, middle initial, and first name clearly in the designated fields.
4. Enter your CAQH number, degree, date of birth, DEA certificate number, social security number, and tax identification number in the corresponding fields.
5. List the languages you speak and your specialty, ensuring all information is accurate.
6. Provide your NPI number, group practice name, practice contact name, and practice contact email address.
7. Include your practice contact phone number, primary office address, billing office address, office telephone number, billing telephone number, office fax number, and billing fax number.
8. After filling Part I, review all entries for accuracy. If you have a completed credentialing application with CAQH, you will need to fax the completed form and a W-9 form to Anthem’s provider contracting department.
9. If you do not have an up-to-date application with CAQH, submit Part I to begin the CAQH credentialing process. After completion of the CAQH application, return to fill out and send the signed Physician Data Sheet form and W-9 form.
10. Finally, once all sections are completed, save your changes, download, print, or share the form as necessary.

Start completing your Physician Data Sheet Form - Anthem online today!