Loading
Get Credentialing Application Addendum For ... - Emblemhealth
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the CREDEntiAling APPliCAtion ADDEnDum FoR Registered Physician Assistant - EmblemHealth online
Filling out the Credentialing Application Addendum for Registered Physician Assistant with EmblemHealth can seem like a daunting task. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.
Follow the steps to successfully complete the application addendum.
- Click ‘Get Form’ button to access the Credentialing Application Addendum. This will allow you to view and edit the document needed for submission.
- Enter your name and title in the designated fields at the top of the application. Make sure that the information you provide is accurate and up-to-date.
- Gather and submit the original application form alongside this addendum. Ensure that you include a collaborative practice agreement with an EmblemHealth participating provider.
- Complete the Collaborative Practice Agreement section by providing the name, address, phone number, license number, NPI number, Directory ID number, and ZIP code of the EmblemHealth physician with whom you are collaborating.
- Sign and date the Collaborative Practice Agreement, confirming your commitment to work collaboratively within your scope of practice.
- Read and complete the Physician Assistant Consent and Release Form. This section requires you to acknowledge your responsibility for providing sufficient information and agreeing to abide by EmblemHealth's guidelines.
- Authorize the investigation and release of information by signing the relevant section. This allows EmblemHealth to validate your licensure and experience.
- Sign and date the consent to confirm that all information provided in the application is true and complete to the best of your knowledge.
- Once you have completed all sections and fields of the form, review for accuracy. After confirming that all the information is correct, you can save changes, download the completed form, print it, or share it as needed.
Complete your application online today and ensure a smooth submission process.
You can open your fillable PDF form in Adobe Acrobat by choosing “Tools” > “Prepare Form”, then use the toolbar to add form fields. To insert a text box in a PDF, go to “Tools” > “Edit PDF” > “Add Text”, and drag to draw a rectangle on your PDF form.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.