Get Tenncare Provider Number And Change Of Ownership Form

Completing the Tenncare Provider Number And Change Of Ownership Form online is a crucial step for healthcare providers seeking to maintain compliance. This guide provides step-by-step instructions to ensure you fill out the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the Tenncare Provider Number And Change Of Ownership Form online and open it in your chosen editor.
2. Indicate your application type by selecting one from the list (e.g., New Registration, Change of Ownership). This helps define the purpose of your form submission.
3. Provide the legal business name and doing business as (DBA) name. Ensure these match the registrations on your IRS documents to avoid discrepancies.
4. Enter the practice location details, including street address, city, state, zip code, phone and fax numbers. Be accurate, as this information is vital for communication.
5. Fill in all required identification numbers including your Federal Tax ID, NPI Number, and Medicaid Provider Number. This section is essential for your identification as a provider.
6. Document all necessary certifications and licenses by uploading copies within the form, as these verify your authority to operate as a healthcare provider.
7. Review and affirm the Application Surety Statement to ensure that the information submitted is accurate and complete.
8. Sign and date the form to validate your submission. This signature can be electronic when submitting the form online.
9. After completing all sections, save your changes. You can opt to download or print the form for your records before submitting electronically.

Complete your Tenncare Provider Number And Change Of Ownership Form online today to ensure your compliance and streamline your provider registration process.