Get Educators Mutual Providers

This guide is designed to assist users in completing the Educators Mutual Providers form. The following instructions will provide clarity on each section to ensure a seamless online filing experience.

Follow the steps to effectively complete the form.

1. Press the ‘Get Form’ button to access the Educators Mutual Providers form. This action allows you to retrieve the form and open it for editing.
2. Begin by entering your last name, first name, and middle initial in the designated fields. Ensure these names are spelled correctly as they will be used for identification purposes.
3. Input your social security number in the appropriate field, ensuring that the number is accurate as it is crucial for verification.
4. Fill in the clinic or office name where you practice. Indicate both NPI numbers if applicable and mark the box to identify which NPI is utilized for billing purposes.
5. Provide the principal office location details including street address, city, state, zip code, and county. If there is a secondary office, complete those details in the subsequent fields.
6. Input the telephone numbers and email addresses for both the principal and secondary locations. Include the tax ID numbers as required.
7. If your billing or correspondence addresses differ from the office address, provide those details in the respective sections.
8. Fill in the provider’s date of birth, and provide the name of the office manager along with details pertaining to your state licensure and DEA number.
9. Select your principal fields of specialization by checking the relevant boxes and provide your liability carrier and policy number.
10. Complete the malpractice history section by detailing any claims made in the past seven years. Attach explanations for each incident if applicable.
11. Provide your educational background including the school of education, location, and year graduated, along with detailed internship and residency experiences.
12. Answer questions regarding any partners or associates, suspensions, investigations, and any criminal convictions.
13. Clarify your patient availability, office hours, and limitations on patient demographics, as well as care coverage arrangements.
14. Ensure that you compile and submit the required enclosures detailed on the form alongside your application.
15. After completing all sections, review the information for accuracy, then save the changes. You can download, print, or share the completed form as needed.

Take the next step in your credentialing process by completing the Educators Mutual Providers form online today.