Get Provider Disclosure Form - Delaware Physicians Care

Filling out the Provider Disclosure Form is an essential step for providers enrolling with Delaware Physicians Care. This guide provides a clear, step-by-step approach to navigating each section of the form online, ensuring you can complete it accurately and efficiently.

Follow the steps to successfully complete the Provider Disclosure Form.

1. Click ‘Get Form’ button to obtain the Provider Disclosure Form and open it for editing.
2. In the 'Name of Entity/Individual' field, enter the full name of the entity or individual submitting the disclosure.
3. Respond to questions 1-3, indicating whether the provider or any individuals with ownership interests have ever been convicted of a criminal offense related to Medicare or Medicaid.
4. For fiscal agents and providers (excluding individual practitioners), answer questions 4-6 by listing individuals with ownership interests and any relationships among them.
5. Review all entries for accuracy before saving changes, downloading, printing, or sharing the completed form as necessary.

We encourage you to complete the Provider Disclosure Form online to ensure compliance and facilitate your enrollment process.