Get Ancillary Practitioner Data Form - Nutritional Counseling

Filling out the Ancillary Practitioner Data Form for Nutritional Counseling is an essential step for practitioners seeking to provide nutritional services through Tufts Health Plan. This guide will help you navigate the online form with ease, ensuring you supply all necessary information accurately.

Follow the steps to complete the form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your general information. Fill in your last name, first name, and middle name as they appear in official documents. Provide your Individual NPI and degree or specialty. Additionally, enter your date of birth and Social Security number.
3. Next, provide your contact details, including your email and any applicable group or practice name. Indicate if you are joining a group practice.
4. Complete the CAQH information section by answering whether you are a Medicare participating provider and ensuring your CAQH application is updated and reattested. If applicable, include your CAQH ID number.
5. In the payment information section, provide your payee NPI and Tax ID number. Specify the payee's information and ensure the payment address matches that provided in the W-9 and CAQH.
6. List your practice address, ensuring to include contact numbers, service hours, and any language services available at your location.
7. Fill out the credentials section by checking all applicable qualifications and providing any additional documentation requested.
8. Ensure to attach all required credentialing documents, including proof of professional liability insurance, general liability insurance, and any other specified documents.
9. Before submission, review your form for completeness and accuracy. Save changes, and then download or print the form for your records.
10. Finally, submit the completed form either by faxing it to 617-972-9591 or mailing it to the specified address for the Credentialing Department.

Complete your Ancillary Practitioner Data Form - Nutritional Counseling online today for a smooth application process.