Get The Cfi Provider Enrollment Application - New Hampshire Healthy

Filling out The CFI Provider Enrollment Application is an essential step for providers wishing to participate in the New Hampshire Healthy program. This guide will walk you through the process of completing the application online, ensuring you understand each section and field in detail.

Follow the steps to successfully complete the application.

1. Click ‘Get Form’ button to access the application and open it for filling out.
2. Begin by providing your legal name, tax identification number, Medicaid number, state license number, national provider ID, and Medicare number in the legal information section. Make sure all information is accurate and reflective of your current status.
3. In the primary facility information section, fill in the location name (doing business as), phone number, primary contact name, email, and address, including city, state, zip code, and county. Ensure all contact information is correct for communication purposes.
4. Complete the service section by specifying your working hours for each day of the week. Answer whether you will be providing services at least five days per week and if you employ physician assistants, certified nurse midwives, or nurse practitioners.
5. Indicate if you will be accepting new patients, provide details about any foreign languages spoken, and clarify if your practice is limited to certain age groups. If yes, provide the specific age restrictions.
6. In the billing information section, designate who will be receiving the payments and provide their address, city, state, zip code, phone number, and any credentialing/billing contacts that may need to be reached out to.
7. In the counties serviced section, select all counties where services will be provided. This ensures clarity on your operational area.
8. Next, choose all types of services you will offer from the provided list. This helps in accurately representing the range of your services.
9. If applicable, list any affiliations you have with other healthcare organizations, including facility name, tax ID, address, and the services they provide.
10. Once all sections are complete, review your application for accuracy. Save changes, and if necessary, download, print, or share the filled form as required for your submission.

Complete your application online to ensure a seamless enrollment experience.