Get Contract Application - Provider Communications - Keystone First

Filling out the Contract Application for Provider Communications with Keystone First is a straightforward process. This guide will help you navigate each section of the form, ensuring that you provide the necessary information accurately.

Follow the steps to complete your online application smoothly.

1. Click the ‘Get Form’ button to access the Contract Application and open it in your preferred online editor.
2. Select the contract type relevant to your services by marking the appropriate box for Medicaid, Medicare, or both. This helps categorize your application accurately.
3. Enter your practice name as you would like it to be listed. This is important for identification in the Provider Directory.
4. Choose your provider type from the options provided (PCP, Specialist, Ancillary, Facility) to further specify your practice.
5. Provide the legal entity name if applicable, along with the Group NPI (10 characters) and Group/Solo TIN/EIN # (9 characters) in the designated fields.
6. Fill out the contact person's information, including their first name, last name, middle initial, degree, and specialty. Ensure accuracy as this information is critical for communication.
7. Enter the CAQH registration number, if registered. If not, list 'N/A' in the field provided.
8. Provide your individual NPI # (10 characters) and the PPID #, ensuring enrollment in the Pennsylvania Medical Assistance Program if you are applying for Medicaid.
9. Input your practice locations (up to eight). Include the street address, building number, city, state, zip code, county, and practice location number for each site.
10. List your contact telephone (with area code), fax number (with area code), and email address in the respective fields.
11. Once all fields are completed, review your form for accuracy. You can save changes, download, print, or share the completed form as needed.
12. Finally, submit your application via email to provider.contracting@keystonefirstpa.com or fax it to 215-863-5472, attention: Renee Hufnell.

Complete your Contract Application - Provider Communications online today!