Get Amerigroup Attestation Form

Completing the Amerigroup Attestation Form online is a straightforward process that requires careful attention to detail. This guide will walk you through each section of the form, ensuring that you understand what information is needed and how to provide it accurately.

Follow the steps to complete the Amerigroup Attestation Form online.

1. Press the ‘Get Form’ button to obtain the Amerigroup Attestation Form and open it for editing.
2. In Section II, fill out your provider information. This includes your physician name, telephone number, street address, Tennessee Medicaid number, city, provider NPI number, contact name, state, MCO provider number, ZIP code, and tax identification number.
3. Next, move to Section III and complete the attestation section. Indicate your specialty or subspecialty designation by checking at least one option. Additionally, confirm that your designation is supported by the required criteria by selecting the appropriate checkboxes.
4. If you are board certified, proceed to Section IV. Here, confirm your board certification by checking the appropriate box and provide the names of your certifying boards and the specific specialty and subspecialty certifications.
5. In Section V, if you are attesting to supervising mid-level or nonphysician practitioners, provide the names and required details of those practitioners, ensuring all fields are accurately filled.
6. Finally, Section VI requires your signature. Sign and print your name, and date the form to complete the attestation process.
7. After filling out the form, review all entries for accuracy. Save your changes, and then download, print, or share the completed form as necessary.

Start completing the Amerigroup Attestation Form online today!