Get Attachment A *please Fax Completed Agreement And Form Cclink ... - Cchealth

Filling out the Attachment A *Please Fax Completed Agreement And Form CcLink ... - Cchealth is essential for accessing the CCLink Provider Portal. This guide will walk you through each section of the form, ensuring you complete it accurately and effectively.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the document editor.
2. Fill in the practice name in the designated field, ensuring it reflects the registered name of your practice.
3. Complete the address section, including street, suite number, city, zip code, and phone number. Make sure this information is accurate and up-to-date.
4. Provide the primary point of contact's name, phone number, and email address. This person will be responsible for communications regarding the form.
5. Enter your tax ID number in the specified cells. If you are a biller, also include the tax ID numbers of the groups you are contracted with to bill CCHP.
6. List each individual who requires access to the CCLink Provider Portal in the table provided. Fill in their last name, first name, middle initial, phone number, and email address.
7. For each individual listed, select one of the four roles: Provider, Nurse, Office Staff, or Manager. Please note that the Office Staff role does not allow access to clinical information.
8. Indicate whether to add or delete a user by checking the corresponding boxes.
9. Review all entered information carefully to ensure accuracy before finalizing the form.
10. Once completed, save your changes, and consider downloading, printing, or sharing the form as required.

Complete your form online now to ensure a smooth application process.