Get Cheyenne, Wy 82003

The Cheyenne, WY 82003 form is essential for individuals and organizations seeking to enroll as providers in the Wyoming EqualityCare program. This guide offers a clear and supportive approach to completing the form online, ensuring that all necessary information is accurately provided.

Follow the steps to successfully complete the Cheyenne, WY 82003 online.

1. Click the ‘Get Form’ button to access the Cheyenne, WY 82003 form and open it in your preferred digital editor.
2. Begin by entering your name and business organization information in the designated fields. Ensure accuracy in the legal name and any 'Doing Business As' (DBA) names, along with your Social Security Number or Tax Identification Number.
3. Fill out the address information section. Include the service location address, office address, and any necessary fax numbers. Be sure to specify the primary practice location if services are offered at multiple sites.
4. Complete the provider certification and registration information, ensuring to include any relevant pharmacy registration details along with your requested begin date.
5. Identify and check your provider taxonomy code from the provided list in the relevant section. If applicable, complete separate applications for additional taxonomy codes.
6. Provide ownership information for any persons who hold a 5% or more ownership stake in your practice. This includes their names, dates of birth, and relationship to other owners.
7. Input your licensure details. Ensure to attach copies of any required licenses as per the provider taxonomy.
8. Answer the additional provider participation information inquiries, including Medicare participation and provider group details, if applicable.
9. Review and complete any necessary certification statements to ensure compliance with state and federal requirements specified in the form.
10. Finally, save your completed form. You can download, print, or share your filled-out Cheyenne, WY 82003 form as needed.

Begin filling out your Cheyenne, WY 82003 form online today to streamline your provider enrollment process.