Get Practitioner Information Form - Molina Healthcare

Completing the Practitioner Information Form for Molina Healthcare is essential for ensuring a smooth contracting process. This guide will provide clear instructions to help you fill out the form accurately and efficiently, enabling you to submit your application with confidence.

Follow the steps to successfully complete the form online.

1. Use the ‘Get Form’ button to access the Practitioner Information Form and open it in your preferred editor.
2. Begin by entering your CAQH ID number if you are already a participant. If not, select the option indicating you would like to participate.
3. Provide your individual NPI (National Provider Identifier) and specify your provider type (e.g., MD, PT). Additionally, identify your directory category.
4. Fill in your personal details including middle initial, first name, last name, last four digits of your SSN, and date of birth.
5. Indicate whether you will be providing telemedicine services to Molina members and confirm your ability to submit claims electronically.
6. Specify your primary specialty and secondary specialties if applicable.
7. List your primary practice information, including whether you are practicing solo or as part of a group/clinic, along with the facility name and NPI if not solo.
8. Complete your physical address details, including street address, city, county, state, and ZIP code, followed by your contact phone and email.
9. If needed, add alternate practice information, including any group names and TINs.
10. Finally, provide your credentialing contact information, including the contact's name, phone number, and email.
11. Once all fields are completed, you can save changes, download a copy, print the form, or share it for submission.

Get started today by filling out your Practitioner Information Form online.