Get Supplemental Form - Caqh - Caqh

This guide provides clear instructions on how to accurately complete the Supplemental Form - CAQH online. Each section of the form is detailed to ensure users understand the requirements and avoid common pitfalls.

Follow the steps to successfully complete the Supplemental Form - CAQH.

1. Press the ‘Get Form’ button to access the Supplemental Form - CAQH online.
2. Begin with section one, 'Personal Information and Professional IDs.' Enter your last name, first name, and any middle names as they appear legally. Ensure to mark if you have used another name previously and provide the dates.
3. In the same section, input your Social Security Number, National Identification Number (if applicable), and gender. Complete all necessary fields marked with an asterisk (*), as they are required.
4. For the 'Professional IDs' subsection, list all relevant licenses and certifications, including state medical licenses and DEA registration. Use the Professional IDs Supplemental Form if additional space is needed.
5. Proceed to section two, 'Education and Training.' Fill out the details of your medical and professional education, ensuring your start and end dates for each institution align with the requirements.
6. In section three, provide your primary specialty information. Complete the necessary fields and codes as indicated.
7. Section four requires your primary practice location details. Verify the address, contact methods, and confirm if you are currently practicing there.
8. As you fill in any additional sections, follow the prompts to complete all subsections as applicable, including work history, hospital affiliations, and disclosure questions.
9. Once you have completed the form, review all entries to ensure accuracy. Save your changes before proceeding to download, print, or share the form.

Visit the CAQH platform to begin filling out your Supplemental Form online today.