Get Provider Application - Interwest Health

Completing the Provider Application - Interwest Health online can seem overwhelming, but this guide will provide you with clear instructions to help you fill out the necessary information accurately and efficiently. Follow the steps outlined below to ensure your application is filled out correctly.

Follow the steps to complete your Provider Application effectively.

1. Click ‘Get Form’ button to obtain the form and access it in your browser.
2. Begin by entering your personal information. Fill in your name, sex, and date of birth in the designated fields. You may also indicate any foreign languages you speak.
3. Proceed to the professional information section. Specify your primary specialty and indicate if you are board certified. If applicable, include other specialties and unique focuses.
4. In the practice location section, provide details about your primary and secondary practice locations, including names, addresses, phone numbers, and emails. If you have more than two locations, attach a separate document.
5. Complete the billing address section, only if it differs from your practice address, by entering the required information.
6. Next, fill out the provider identification section. Include your tax identification number, social security number (if applicable), NPI number, license information, and DEA or CDS number.
7. In the education and training section, indicate the year completed and the institutions you attended, including details about your medical school, residency, and fellowship.
8. Move to the work history section. List your most recent five years of employment, along with explanations for any gaps in employment that exceed six months.
9. In the hospital staff privileges section, list the hospitals where you currently hold active privileges.
10. For malpractice insurance, provide details about your coverage, including dates and amount per occurrence. If you have federal tort coverage, check the appropriate box.
11. Answer the attestation questions truthfully. If you respond 'yes' to any, provide a detailed description of the incidents as requested.
12. Finally, review the attestation statement, sign, and date the application in the designated areas.
13. Ensure you submit all required documents listed at the end of the application, along with a signed agreement. Once completed, save your changes, and download, print, or share the application as needed.

Start your application process now by filling out the Provider Application - Interwest Health online.