Get Number Apd-ar-14-023 - Hijossaludablesoregon

This guide provides a comprehensive approach to completing the Number APD-AR-14-023 - Hijossaludablesoregon online. It aims to support users in filling out the required information accurately and efficiently.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the online form and open it in your preferred document editor.
2. Complete Section 1, which includes the identifying information for the provider. This includes the full legal name, date of birth, doing business as (DBA) name, Social Security Number (SSN), and email address.
3. Fill out Section 2 for provider incorporation details if applicable. Indicate the official IRS business name, DBA name, business type, and tax identification number.
4. In Section 3, provide complete address information for the provider, including the primary business address and any alternative mailing address, if different.
5. For Section 4, enter provider credential information. This includes the date of approved CHC fitness determination, the level of CHC, and a signed ODDS Provider Enrollment Application & Agreement form, which must be submitted alongside this application.
6. Complete Section 5 by indicating the associated CDDP and/or Brokerage names that the provider will be affiliated with.
7. Once the form is fully completed, you may submit it via secure email, fax it to the indicated number, or send it by US mail to the Provider Relations Unit.
8. After submitting the form, ensure you keep a copy for your records. You can save changes, and if further actions are needed, such as printing or sharing the form, do so appropriately.

Begin filling out your document online today to ensure timely submission and compliance!