Follow the steps to successfully complete your application online.

1. Click ‘Get Form’ button to access the application and open it in your chosen program for editing.
2. Begin by completing the Provider Identification section. Enter the legal business name, any applicable 'Doing Business As' name, and the contact person's information along with their email.
3. Fill in the Tax ID numbers, Medicaid numbers, Medicare numbers, and Long-Term Care vendor number as required.
4. In the Provider Type section, select all applicable facility types from the list provided by checking the corresponding boxes.
5. Ensure that you have included any necessary enclosures, such as recent CMS or state surveys for all selected facility types.
6. Provide the Primary Office/Service Address, including the practice location name, full address, phone, and fax numbers.
7. Complete the Billing Information section with the appropriate billing name, address, and contact details.
8. If applicable, include Secondary Office/Service Address information similar to the primary address.
9. Fill out the National Provider Identifier (NPI) section, listing the relevant details for each location.
10. Complete the Licensure section with details about your current licensure and attach a copy of the license.
11. Input the necessary Accreditation/Certification information and attach copies of relevant documents.
12. Fill out the Insurance section, providing details about your general and professional liability coverage.
13. Complete the Disclosure of Ownership and Control Interest Statement, answering all questions accurately.
14. In the Remarks section, add any additional information required and verify that all necessary enclosures are included.
15. Once the form is complete, save your changes and consider downloading or printing the completed application for your records.

Complete your Facility/ Ancillary/ Long-term Care Application online today for a smoother process!