Get Provider Application Form Eb 197 - Guardian Group

Completing the PROVIDER APPLICATION FORM EB 197 for Guardian Group is essential for healthcare providers seeking to register. This guide will provide you with detailed, step-by-step instructions to assist you in filling out the form accurately and efficiently online.

Follow the steps to successfully complete the application form

1. Press the ‘Get Form’ button to obtain the form and launch it in an appropriate online editing tool.
2. In Section A, complete the applicant/provider name field, and select the type of medical practice you belong to from the provided options, such as medical, optical, dental, pharmacy, laboratory, or radiology. Additionally, specify your specialty and fill in your professional registration number and registration authority details.
3. In Section B, provide your practice location's address, including the city and parish. Indicate the operating days and hours for your practice. Specify whether the location is currently in operation by selecting yes or no. Include the name and contact details of a designated contact person at your practice.
4. If applicable, Section C allows you to add an additional practice location. Fill out the same required details as in Section B: address, city, parish, operating days and hours, operational status, and contact person information.
5. In Section D, if your mailing address differs from your practice location, please provide it, along with corresponding city and parish details. Answer whether your license has ever been revoked or suspended. If yes, you must include proof of reinstatement.
6. Finalize your application by signing and dating the form in the designated areas for the provider's signature. If applicable, secure an additional signature from another provider.
7. After completing all sections and ensuring accuracy, save your changes. You may then choose to download, print, or share the completed form as required.

Get your provider application form completed online today.