Get Provider Data Sheet - Sagamore Health Network Inc

Completing the PROVIDER DATA SHEET is an essential step in ensuring that your provider information is accurately captured by Sagamore Health Network Inc. This guide will walk you through each section of the form, providing step-by-step instructions to make the process straightforward and efficient.

Follow the steps to complete the PROVIDER DATA SHEET accurately.

1. Click ‘Get Form’ button to access the form and open it in your chosen editor.
2. Begin by filling out your personal information in the Provider Demographics section. Enter your last name, first name, middle initial, and provide your Social Security Number (SSN), date of birth (DOB), and preferred language(s).
3. Input your professional identifiers, including your National Provider Identifier (NPI) number, license number, and the state you are licensed in. Also, indicate your hospital affiliation and tax identification number (Tax ID #).
4. Specify your primary and secondary specialties. You may also indicate if you are a primary care provider (PCP).
5. In the Address Information section, enter your primary practice name, billing name, and addresses, including city, state, county, phone number, and zip code for both your primary practice and billing locations.
6. Complete the Credentialing Contact Information by providing the name, phone number, email address, and fax number of your office contact or manager.
7. Before submitting, review the completed form for accuracy. You must ensure that the information provided is current and complete to avoid delays in credentialing.
8. Finally, sign and date the form. If submitting it alongside a contract, ensure both documents are mailed together to the specified address or faxed according to the instructions.

Start completing your PROVIDER DATA SHEET online today to ensure a smooth credentialing process.