Get Practitioner Application Form - First Health - Coventry Health Care

Filling out the Practitioner Application Form for First Health - Coventry Health Care can be a straightforward process when guided appropriately. This comprehensive guide provides you with step-by-step instructions to ensure you successfully complete the application online.

Follow the steps to accurately complete the Practitioner Application Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor. This allows you to begin filling out your information.
2. Begin with the general information section. Enter your CAQH number, full name, any previous names, birth date, and social security number. If a section does not apply to you, mark it as N/A.
3. Continue to fill out your professional information. Include your Medicare and Medicaid provider numbers, NPI numbers, and indicate your participation status by selecting the applicable types.
4. Complete the primary office information. Fill in the type of practice, office name, address, contact details, Medicaid number, and your availability to see patients.
5. If applicable, provide details regarding your secondary office information, ensuring to follow the same structure as in step 4.
6. List your group partners, if any, and their participation status with Coventry. Make sure to provide all required information clearly.
7. Fill out the call coverage section. Name the physicians who will cover your calls and indicate their participation with Coventry.
8. Complete the education and training section. You can attach your curriculum vitae instead, making sure to account for any gaps in training.
9. Provide your work and practice history for the past five years, explaining any significant gaps.
10. List all states where you hold a medical or professional license along with their details.
11. Detail your narcotic certification and provide your DEA number(s) as required.
12. Answer all questions in the Confidential/Personal Information section, making sure to provide explanations for any 'Yes' responses on a separate page.
13. Upon completion, review all information for accuracy. Save changes, download, print, or share the form as needed.

Complete your Practitioner Application Form online today to begin your application process with First Health - Coventry Health Care.