Get Practice Application

This guide provides step-by-step instructions on how to complete the Practice Application online, ensuring a smooth and efficient process. Following these guidelines will help you provide all necessary information accurately and comprehensively.

Follow the steps to successfully complete the Practice Application.

1. Click ‘Get Form’ button to access the Practice Application form and open it in your preferred editor.
2. Begin by providing your practice information. Indicate whether your practice is a solo practice, partnership, or professional corporation. Include your provider name, corporation name (if applicable), Tax Identification Number (TIN), and address details. Make sure to check the box for multiple billing addresses if necessary.
3. Provide the business contact’s email address and phone number, as well as the practice manager’s contact details. Ensure that the primary office location is filled out, including the office manager's information and hours of operation for each day of the week.
4. List the providers at your practice location, including the applicant. Provide Medicaid numbers for each provider as applicable. If there are multiple office locations, copy the relevant section and fill it out for each location.
5. Detail the languages spoken by both the provider and staff, and indicate whether the practice is equipped to accept patients with developmental disabilities and if the office is handicap accessible.
6. Complete the patient procedure services section by indicating the methods available and if you accept new patients. Include information about procedures such as nitrous oxide or general anesthesia.
7. Proceed to fill in the provider's personal information, including names, Social Security Number, National Provider Identifier (NPI), and licensing information. Ensure to attach copies of any necessary licenses.
8. Complete the professional questions section. Answer each question honestly, and provide explanations for any yes answers on a separate piece of paper.
9. Sign the application where indicated to certify the accuracy of the information provided. Make sure to include the date of signing.
10. Attach any required documents such as the W-9 form, copies of licenses, certificates, and professional liability insurance. Ensure everything is complete before submitting.
11. Finally, save your changes, download, print, or share the completed application as necessary.

Complete your Practice Application online today for a streamlined application process.