Get If You Wish Peach State Health Plan To Retrieve Your Credentialing Application From The Caqh

Filling out the If You Wish Peach State Health Plan To Retrieve Your Credentialing Application From The CAQH is essential for streamlining your credentialing process. This guide will assist you through each section of the form, ensuring you provide the necessary information clearly and accurately.

Follow the steps to complete the form efficiently.

1. Press the ‘Get Form’ button to access the form and open it in your document editor.
2. Enter the date in the designated field at the top of the form.
3. Provide your last name, first name, and middle initial in the appropriate fields.
4. Fill in your date of birth.
5. Include your primary telephone number.
6. Complete the primary office street address, including the suite number if applicable.
7. Add your primary office city and state.
8. Fill in your provider type (e.g., MD, DO, DC) and county.
9. Specify your zip code.
10. Input your Medicaid ID.
11. Indicate whether you are applying as a primary care provider, specialist, or allied health professional by checking the appropriate box.
12. List your specialty.
13. Select whether you are board certified, and if so, provide the board name.
14. Indicate if you are registered with CAQH, and provide your CAQH provider ID if applicable.
15. If you are not registered with CAQH, complete the additional information fields, including primary fax number, email address, and social security number.
16. Fill in the required DEA certificate number, state license number, and licensed state.
17. Input any additional identifiers such as UPIN, NPI, and tax ID.
18. Review all filled sections to ensure accuracy and completeness.
19. Once completed, save your changes, download, print, or share the form as needed.

Complete your document online today to facilitate your credentialing process.