Get Multiplan Prvp077 2009

This guide provides clear, step-by-step instructions for completing the MultiPlan PRVP077 form online. By following these instructions, users can ensure that their application for participation in the MultiPlan networks is completed accurately and efficiently.

Follow the steps to complete the MultiPlan PRVP077 form online.

1. Press the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by indicating how you are applying to join the networks. Choose either 'Individual practitioner' or 'Individual practitioner as part of a group practice'. If applicable, input the Group Name, the number of practitioners, and the MultiPlan Group Contract ID.
3. Fill out the personal information section, including your last name, first name, middle initial, NPI, previous legal name (if applicable), and Social Security number. Select your professional degree and gender, and provide your birth date and title.
4. List all hospitals where you currently have admitting privileges. Include hospital names, addresses, and whether you have admitting privileges directly or through another practitioner.
5. Complete the specialties section by indicating your primary and any additional practicing specialties. Ensure to check if you are board certified and report your board specialty and hospital-based status.
6. Provide information about your education, including the name of the college or university you attended, city, state, and country for each degree, along with the dates attended.
7. Detail your professional history over the last five years. Include the activity or position, the facility or program, city, state, and the specific months and years for each entry.
8. Indicate the languages you speak in addition to English and whether you can communicate in sign language.
9. Attach a copy of your malpractice insurance face sheet and complete the sections on professional liability and general liability insurance, including carrier name, policy number, and expiration date.
10. For each office where you see patients, provide practice, billing, and mailing information. Include the office’s address, phone numbers, office hours, and accessibility details.
11. Complete the employment history section, specifying positions held, employers, and dates. Provide explanations for any employment gaps.
12. Answer the professional questions and sign the attestation section to certify that the information in your application is complete and accurate.
13. Review the application checklist to ensure that all required documents and materials are included, and then submit the completed application via the specified methods.
14. After filling out and reviewing the form, save your changes, download a copy for your records, and prepare for submission.

Start filling out your MultiPlan PRVP077 form online today to ensure a smooth application process.