Get Application For Professional Providers - Triple-s Salud

This guide provides comprehensive instructions on filling out the APPLICATION FOR PROFESSIONAL PROVIDERS online. Each section and field of the form is explained clearly to assist users, regardless of their prior experience with such documents.

Follow the steps to effectively complete your application online.

1. Click ‘Get Form’ button to retrieve the form and open it in your preferred viewer.
2. In Section 1, input your applicant/provider information. Fill in your last name (both paternal and maternal), first name, Social Security Number, date of birth, and gender. Indicate your mailing address and individual email address.
3. Continue to Section 1A if you perform home visits. List all relevant locations if applicable. If not, proceed to Section 1B.
4. Move to Section 1C and respond to the primary office questionnaire regarding state and federal handicap access requirements and leasing status for your office location.
5. Fill out Section 1F with your educational background, including medical school details and specialty attained.
6. Complete Section 2 and respond to questions about any convictions or adverse actions taken against you in the past ten years.
7. In Sections 7 and 8, review the credentials authorization release and provider attestation. Provide your signature and the date.
8. Finally, submit your application via email, fax, or mail as outlined in Section 10.

Complete your APPLICATION FOR PROFESSIONAL PROVIDERS - Triple-S Salud form online to ensure timely processing.