Get 10801 Executive Centre Drive Suite 305 - Novasys Health

Filling out the 10801 Executive Centre Drive Suite 305 - Novasys Health form online is a crucial step for healthcare providers seeking collaboration with NovaSys Health. This guide aims to provide comprehensive, step-by-step instructions to ensure a smooth completion of the form.

Follow the steps to fill out the form correctly.

1. Click the ‘Get Form’ button to access the document and open it for online editing.
2. Begin filling out the form by entering the date mailed and date received at the top. Provide the subprogram details as applicable.
3. For the Provider Application section, input your last name, first name, middle initial, date of birth, sex, and individual NPI.
4. Enter your Social Security number for identification purposes only, followed by the languages you speak and your state license number.
5. List your primary office location. Ensure to attach a complete listing of all practice locations.
6. Fill in your mailing address, clinic name, street address, city, state, zip code, and telephone number.
7. Provide your fax number and any additional clinic-related telephone numbers.
8. Complete the practice information section by indicating whether you are accepting new patients and specifying any restrictions.
9. List all healthcare facilities where you currently have privileges, including admitting facility details.
10. Detail your professional organizations and the length of association for each.
11. Indicate your participation status, specialty, and whether you are board certified, attaching any necessary documentation.
12. Complete the education and training sections, listing your medical school, internship, residency, and fellowship details.
13. Answer health status questions truthfully, especially if a question requires a ‘Yes’ response, as explanations are mandatory.
14. List your call coverage arrangements and any collaborative agreements with physicians if applicable.
15. In the Provider Attestation section, read the statements carefully, sign, and date the application.
16. Finalize your application by saving any changes, printing for your records, or submitting online if available.

Complete your documents online now for a seamless application process.