Get Nurse Practitioner / Physician Assistant Registration Form - Mcms

This guide provides step-by-step instructions for completing the Nurse Practitioner / Physician Assistant Registration Form - Mcms online. Follow these instructions to ensure that your application is filled out accurately and efficiently.

Follow the steps to complete your registration form online.

1. Click ‘Get Form’ button to access the registration form and open it in your preferred online editor.
2. Start by entering your date of birth, applicant name (last name, first name, middle initial), and gender by selecting the appropriate checkbox.
3. Indicate the effective date of your registration in the provided format (mm/dd/yyyy).
4. Select one of the options provided to indicate your professional role: Nurse Practitioner, Physician Assistant, CDE, CRNA, or Nutritionist.
5. Fill out the demographic information. This includes your primary office address, office phone, and any additional office addresses. Ensure you provide street-level information and avoid using P.O. Box addresses.
6. Complete the correspondence and remittance address sections with valid mailing addresses, remembering to exclude street-level information for P.O. Boxes.
7. Provide details of your education/licenses by including your graduate school, graduation date, degree obtained, license number, expiration date, as well as your DEA, Medicaid, Medicare numbers, and NPI number.
8. For the liability insurance section, select whether you are the policyholder for malpractice insurance, the collaborating physician, or another entity, and include a copy of your current certificate.
9. Sign the form with your name and date to attest to the information provided.
10. Lastly, provide the collaborating physician's information if applicable, including their name, NPI number, specialty, medical practice group name, and billing tax ID number. This section also requires the collaborating physician's signature and date.
11. Once all sections are filled out accurately, you can save your changes, download, print, or share the completed form as needed.

Complete your Nurse Practitioner / Physician Assistant Registration Form online today.