Get Provider Information Sheet - Infinedi

Filling out the Provider Information Sheet - Infinedi is essential for setting up your provider account. This guide offers a comprehensive overview of each section of the form to assist you in completing it accurately and efficiently.

Follow the steps to accurately complete the Provider Information Sheet

1. Click the 'Get Form' button to obtain the form and open it in the editor, allowing you to start the completion process.
2. In Section 1, indicate whether you want your account set up as a Group/Practice or as an Individual Provider by selecting the appropriate option. Provide the Group/Practice name or the Individual Provider's name along with their credentials. Next, specify the Provider's specialty, Social Security Number (SSN), and their contact information including address, city, state, zip code, phone number, fax number, and email.
3. In Section 2, you will detail your participation in insurance programs. If you do not have a certain number, write 'N/A' or 'pending' as appropriate. Fill in the Individual and Group numbers for Medicaid, BC/BS, Medicare, Railroad Medicare, Tricare, and any other relevant fields including your State Medical License number, NPIs, Taxonomy Codes, and CLIA number.
4. In Section 3, select how you wish to receive payment for claims by providing either the Group Tax-ID, Individual Tax-ID, or Provider Social Security number. Make sure to include the respective name, address, city, state, and zip code associated with the payment.
5. Once you have completed all sections of the form, review your entries for accuracy. You can then save your changes, download, print, or share the completed form as needed.

Complete your Provider Information Sheet online to ensure a smooth enrollment process.