Get Mcc Instate And Out-of-state Individual Provider Joining A ... - Tn.gov - Tn

This guide provides a clear and supportive walkthrough for completing the MCC instate and out-of-state individual provider joining a group form required by the Tennessee TennCare/Medicaid Program. By following these detailed instructions, users can ensure their enrollment forms are accurately filled out and submitted.

Follow the steps to accurately complete your enrollment form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin with the checklist provided at the start of the form, ensuring you have all required documents listed, such as your Medicaid provider number, individual application, and any necessary certifications.
3. Fill in your complete name as shown on your license. Indicate whether this is for new enrollment, reactivation, adding a practice location, or revalidation.
4. Provide your practice location address without using a P.O. Box. Be sure to include city, county, state, and ZIP code.
5. Complete the pay-to name and address sections as they appear on the IRS and W-9 forms.
6. Enter your Tax Identification Number (IRS) and any required identification details, including your social security number and date of birth.
7. Respond to additional questions regarding your medical specialty and other professional qualifications listed on the form.
8. Sign and date the form, ensuring your signature is original, as this is required for processing your application.
9. Once all fields are completed, review the form for accuracy. Save changes, and download or print the document as needed for your records.
10. Submit the completed application along with the required supporting documents by mail to the Bureau of TennCare at the specified address.

Start filling out your documents online today to ensure timely enrollment.