Get Ind Pract Prov Add Term - Ccstpa

Completing the Ind Pract Prov Add Term - CCStpa is an essential step for adding or terminating an individual practitioner in your clinic. This guide provides a clear, step-by-step overview to assist you in filling out the form effectively and efficiently.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date of request in the designated field at the top of the form. This date is important for tracking purposes.
3. Fill in the individual practitioner information, including their last name, first name, any previous names, gender, suffix, and middle initial. Ensure all names are spelled correctly.
4. Provide the date of birth and social security number of the practitioner. This information is required for identification and credentialing.
5. List the practitioner's specialty, followed by their state medical license or certification number and NPI/UMPI number. Attach copies of relevant licenses as specified.
6. If there are any changes to the practitioner's demographic data, indicate the effective date of the change and complete the fields for new last name, first name, specialty, license number, and NPI/UMPI number as needed.
7. If adding or removing a practitioner, specify the effective date and fill out their practice locations. Each location requires the clinic or hospital name, street address, city, state, and zip code.
8. Indicate if the practitioner is accepting new patients and provide the primary care manager's details if applicable.
9. Fill out the person completing the form section, including their email address, effective date, signature, and phone number.
10. Review all entered information for accuracy before deciding to submit the form. You can then save changes, download, print, or share the completed form.

Start filling out your documents online to streamline your workflow.