Get Non-delegated Group Add-on Form

Filling out the NON-DELEGATED GROUP ADD-ON FORM is an essential task for those looking to add providers to their existing group practice. This guide will walk you through each step of the process to ensure accurate and complete submission.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to access the NON-DELEGATED GROUP ADD-ON FORM and open it in your preferred editor.
2. In the first section, provide the Contract Entity details. Input the IPA of New Mexico as #NM4220 and ensure it is accurate.
3. Next, enter the Group/DBA Name in the designated field along with the corresponding State abbreviation.
4. Fill in the Practice/Institution name accurately, which reflects the setting where the providers will be practicing.
5. Insert the Group Primary TIN# in the relevant space. This number is crucial for tax identification purposes.
6. Indicate whether you are adding an individual provider or multiple providers by checking the appropriate box.
7. Ensure that you have gathered all necessary credentialing data elements such as the current CV, W9 IRS Form, State Controlled Substance Certificate, and any malpractice cases documentation.
8. Once you have completed all fields and attached necessary documents, review the entire form for accuracy.
9. Finally, you can save changes, download, print, or share the completed form using the appropriate options in your editor.

Complete your documents online today to ensure a smooth submission process.