Get A Mahp Standard Practitioner Application - Coventry Medicaid ...

Filling out the A MAHP Standard Practitioner Application is an essential step for practitioners wishing to join the Coventry Medicaid network. This guide provides clear, step-by-step instructions to help you navigate the completion of the application online.

Follow the steps to complete your application efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by providing your personal information. Fill in your full name, degree or professional title, home address, and contact details. Ensure to include other names you may have used and your date of birth.
3. Specify your citizenship status and the languages you speak/write, if applicable. You must also include your Social Security number.
4. Indicate the practice specialty for which you are seeking affiliation, selecting the appropriate options whether you are a primary care physician, specialist, or allied health practitioner.
5. Complete the primary office practice information section. Provide details about the health plans accepted, your practice type, and office location.
6. Fill in the necessary sections regarding coverage and admitting arrangements, including information about 24-hour medical coverage and hospital affiliations.
7. Proceed to the medical and professional school section by listing all institutions attended and degrees awarded, including graduation dates.
8. Detail your hospital and work history, ensuring to chronologically list each practice location and the relevant experience you have had.
9. Review and answer the sections about professional licenses, board certification, and references. Ensure to provide accurate details for each section.
10. Complete the attestation statement, ensuring you sign and date where indicated. Don’t forget to include the Consent to Release of Information form and any necessary attachments.
11. After completing your application, save changes to the document. You may also download, print for your records, or share it as needed.

Take the next step in your professional journey by completing the A MAHP Standard Practitioner Application online today.