Get Mid Level Providers Form

Filling out the Mid Level Providers Form online can be a straightforward process if you follow the correct steps. This guide provides detailed instructions to help you complete each section of the form accurately.

Follow the steps to complete the Mid Level Providers Form online

1. Press the ‘Get Form’ button to access the Mid Level Providers Form. This will open the document in your preferred editing tool.
2. Begin by providing your demographic information. Fill in your last name, first name, date of birth, gender, and any other languages spoken. Don't forget to include your Social Security number and area of specialization.
3. In the education section, enter the name of your graduate school, the degree obtained, and the year you graduated.
4. Next, complete the license numbers section by providing your DEA number, DEA state, state license information, state license number, and Type 1 NPI number, as this is essential for registration.
5. For the insurance section, indicate the name of your current professional liability carrier, their address, the amount of coverage, and the policy number with its effective dates.
6. Proceed to the practice site information section. You'll need to state the effective date, the group name, service address, city, phone number, fax number, collaborating physician's name and specialty, and the employer/practice tax ID number. Also, specify your hours per week at this practice.
7. If you have additional practice site information, repeat step 6 for the second site.
8. Once you have filled out all sections, review your information for accuracy. Make any necessary corrections before finalizing.
9. Finally, save your changes, download the form, print it, or share it as required. Remember to fax only the completed registration form to the appropriate PR Regional office listed in the instructions.

Start filling out your Mid Level Providers Form online today to ensure a smooth registration process.