Get Agency Provider Additional Services Application - Eastpointe.net - Eastpointe

This guide provides clear and structured instructions on how to complete the Agency Provider Additional Services Application for Eastpointe. By following these steps, users can ensure they provide accurate and comprehensive information while filling out the form online.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the Agency Provider Additional Services Application, allowing you to open and edit the document online.
2. Begin with the application date, entering the current date in the designated field.
3. Fill in the provider name and the services requested to provide, ensuring clarity and accuracy.
4. Move to Section I, which covers Corporate Information. Review the fields and make any necessary corrections related to your agency, including legal name, Federal Tax ID, organization address, and county.
5. If applicable, provide details about the national accreditation status, including the accrediting organization and relevant dates.
6. List the primary contact information thoroughly, including name, title, email address, and various phone numbers.
7. Complete information for the Clinical/Medical Director and provide all necessary identification numbers, such as the Medicaid and National Provider Identifier (NPI) numbers.
8. Proceed to Section II for Site Enrollment. If multiple facilities exist, replicate the fields for each site, including the facility name, address, and contact information.
9. Fill out all specified details regarding the Facility/Site Director, including their education and credentials.
10. Answer pertinent questions regarding previous applications and licensing status, attaching copies of any licenses as required.
11. Thoroughly address questions regarding facility staffing and emergency coverage, ensuring to consider the diverse populations served.
12. Provide detailed descriptions regarding the agency's expertise, including mission, vision, training practices, and recognitions.
13. List all services requested as per the guidelines from the North Carolina Department of Health & Human Services, ensuring to document the required specifications for each.
14. Final values, such as authorization details, including signature, title, and date, must be filled out before submitting.
15. Once all parts of the application are duly filled, review for accuracy and either save changes, download, print, or share the completed form.

Start filling out your Agency Provider Additional Services Application online today!