Get Interested Provider Information Form - Magellan Provider's Home ...

Completing the Interested Provider Information Form is an essential step in the process of joining the Magellan networks. By carefully providing the required information online, you can ensure a smooth submission and facilitate your request for inclusion.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to obtain the Interested Provider Information Form and open it in your editor.
2. In Section I, fill out your personal details if you are an individual or a group member. Provide your last name, first name, middle name, date of birth, gender, license type, license number, degree, social security number, Medicaid ID, email address, and NPI number. Ensure each field is accurately completed.
3. For the mailing address, enter your full address including city, state, zip code, and county. Provide a phone number and, if applicable, a fax number.
4. If you are part of a group practice, specify the group name and note if you have ever been employed by Magellan Health Services.
5. Groups and organizations must complete Section II, detailing the group name, legal name if different, and NPI. Indicate if your organization is currently contracted with Magellan and provide your Medicare number.
6. In Section III, choose your practice categories, age demographics, and languages spoken. This section also provides space for you to list your specialties and to voluntarily share your ethnic background.
7. Review your entries for accuracy and completeness. Once satisfied, ensure to save all changes made to the form.
8. After finalizing your entries, you can download, print, fax, or share the form as needed to submit it to Magellan.

Complete your documents online today to take the next step in joining the Magellan networks.