Get Health Care Registration Form

Filling out the Health Care Registration Form online is an important process for certified registered nurse anesthetists to register their practice details comprehensively and accurately. This guide will provide you with clear, step-by-step instructions to help you complete the form effectively.

Follow the steps to complete the form accurately

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. In the first section, provide your last name and first name. Ensure that both names are spelled correctly as this will be crucial for your records.
3. Enter your date of birth, followed by your gender. Be sure to select the appropriate option by circling or marking your response.
4. Fill in the name of your graduate school and the degree you obtained. This information is vital for verifying your qualifications.
5. Provide your New York State (NYS) license number, along with your Medicaid number, Medicare number, and NPI number. These numbers are essential for your practice registration.
6. Include your DEA number, if applicable. This registration allows you to prescribe controlled substances.
7. List the languages you speak to facilitate communication with diverse patients.
8. Enter the name of your supervising physician. This is crucial for compliance with practice regulations.
9. Provide your primary office address, including the city, state, zip code, and phone number. Make sure this information is accurate for correspondence.
10. Include your fax number and answering service phone number, as well as your email address for effective communication.
11. If you have a secondary office, complete that section as well, including the same details as above.
12. Indicate the policyholder of your malpractice insurance and circle the appropriate response: self, physician/practice, or other.
13. Sign the form where indicated and provide the date of your signature.
14. After completing the form, attach a copy of your license, DEA certificate, CCNA certificate, supervisory agreement, and malpractice insurance documentation.
15. Finally, save your changes, download the completed form, and either print it for mailing or prepare it for electronic submission. Send it to MVP Health Care or fax it to the provided number.

Complete your Health Care Registration Form online today to ensure your practice is properly registered.