Get Mercyonesource

This guide is designed to assist users in completing the Mercyonesource registration form effectively and securely. By following the step-by-step instructions, you will ensure that your submission is accurate and complete.

Follow the steps to complete the Mercyonesource registration form online.

1. Press the ‘Get Form’ button to access the registration form and open it in the editor.
2. Fill in the required provider details including the contracted provider name, provider office name, and provider tax ID number. Ensure all entries are accurate to avoid delays.
3. Provide your contact information, including your office address, phone number, fax number, city, state, and zip code.
4. Designate a Primary Representative from your office. Enter their full name, phone number, and email address.
5. Review the attached Provider Web Portal Agreement and confirm your understanding of the terms and conditions to use the web portal service.
6. Sign the form in the designated area and print your name clearly. Include the date of signing.
7. Fax the completed registration form along with the signed Provider Web Portal Agreement to the provided fax number, ensuring all documents are included.
8. Once submitted, maintain a copy of your documents for your records and wait for confirmation from the Mercy Care Plan.

Complete your registration online today to access the Mercyonesource web portal.