Get Provider Information Form - Cencal Health - Cencalhealth

Filling out the Provider Information Form for CenCal Health is a crucial step for healthcare providers seeking to become part of the network. This guide will provide you with a clear, step-by-step approach to successfully complete the form online.

Follow the steps to complete the form accurately and efficiently.

1. Click 'Get Form' button to access the Provider Information Form and open it for editing.
2. Begin by filling out Section 1, which requires your provider name and contact information, including legal business name, office phone, office email, and office fax. Ensure all information is current and accurate.
3. In Section 2, indicate your billing information. Choose whether you have an in-house biller or use an outside billing service. Provide the necessary contact details accordingly.
4. Proceed to Section 3 to list information about your office staff. You will need to include details for your office manager and any relevant billing contacts.
5. Section 4 requires you to provide your credentials and identification numbers, including NPI, Tax ID, and any relevant licenses.
6. If applicable, fill out Section 5 regarding group contracting or group changes, including group NPI and tax ID.
7. In Section 6, list any hospital affiliations you have.
8. Section 7 asks for your office hours, so be sure to accurately indicate the days and times your practice is open.
9. If you are a specialist, skip Section 8. If applicable, note your access options in this section.
10. Use Section 9 to mention any additional languages spoken by your staff.
11. In Section 10, answer questions regarding accessibility at your facility to comply with disability standards.
12. Section 11 includes a questionnaire regarding certifications you may hold. Complete all relevant questions.
13. If applicable, detail any after-hours procedures for primary care physicians in Section 14.
14. Fill out Section 15 if you provide durable medical equipment or medical supplies, specifying what you offer.
15. Use Section 16 to provide any additional information about your practice that may be valuable.
16. Complete Sections 17 and 18 to add any rendering providers or additional locations related to your practice.
17. Once all sections are completed, save your changes. You can then download, print, or share the completed form as needed.

Complete your Provider Information Form online today for a smoother onboarding experience.