Get Dshs Core Provider Agreement Form

The Dshs Core Provider Agreement Form is essential for providers seeking to enroll in medical assistance programs managed by the Department of Social and Health Services. This guide offers clear, step-by-step instructions to fill out the form online effectively.

Follow the steps to complete the Dshs Core Provider Agreement Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the identifying information in Section I. Enter the owner’s name, effective date, business name, and contact details such as the business phone and mailing address.
3. Next, complete the business's physical address and type of practice. Specify the provider’s specialty and professional license number.
4. In Section II, fill in the details of each provider practicing under the business name, including their name, license number, and relevant identification numbers.
5. Proceed to complete questions related to criminal offenses and debarment status in Section III, ensuring full transparency in disclosures.
6. Review all entered information for accuracy, ensuring compliance with federal and state requirements as detailed in the agreement.
7. Once all sections are completed, save the changes. You may choose to download, print, or share the form as needed.

Complete your Dshs Core Provider Agreement Form online to ensure a smooth enrollment process.