Get Non-credentialed Provider Form - Coventry Health Care Of Delaware

Completing the Non-Credentialed Provider Form is an essential step in becoming a recognized provider with Coventry Health Care of Delaware. This guide offers clear and supportive instructions for filling out the form online, ensuring that you can efficiently provide all necessary information.

Follow the steps to complete the Non-Credentialed Provider Form online.

1. Press the ‘Get Form’ button to access the Non-Credentialed Provider Form and open it for editing.
2. Begin by filling in your general information. Enter your name, degree, gender, address, and contact details. Ensure all entries are accurate.
3. Provide your County, Tax Identification Number, birthdate, and Social Security Number. Input your NPI number and select the type of services you will be providing from the list available.
4. Fill in details for the administrator, including their name, title, and phone number, ensuring that you offer correct contact information.
5. Include information about your managed care contact and billing details. Specify the billing name and address, as well as the contact person for billing queries.
6. Complete the licensure and accreditation section by providing your state license number and attaching your state license. Include your Medicare, National, and Medicaid provider numbers.
7. Input your professional liability insurance carrier information along with the policy number and expiration date.
8. Provide your CLIA waiver number and identification number, followed by your hours of operation for each day of the week.
9. Finally, print your name, sign the form, and date it to certify the accuracy of the information provided.
10. Once all necessary fields are filled out, you can save your changes, download, print, or share the completed form as needed.

Start filling out your Non-Credentialed Provider Form online today to ensure efficient processing.