Get Ash Network Participation Application - Wordpresscom

Completing the ASH Network Participation Application is an essential step for practitioners seeking to join the ASH network. This guide will provide clear and comprehensive instructions to help you easily fill out the application online.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by filling out the 'Identifying Information' section. Provide your first, last, and middle names, any relevant professional distinctions, and a current home mailing address including your phone number and social security number.
3. Proceed to the 'Practice Information' section. Enter the details of your primary practice, including the practice name, address, and contact numbers. If you have additional offices, make use of the 'Additional Office Information' section provided.
4. Next, complete the 'Professional Liability Insurance Information' section. List your current malpractice insurance carrier along with relevant policy details, including policy numbers and effective dates. Make sure to address any relevant questions regarding your malpractice experience.
5. For the 'Professional Education' and 'Professional Licensure/Registration/Certification' sections, input your education history, including professional degrees and training, and provide details about your current and additional licenses.
6. In the 'Professional Work History' section, chronologically list your most recent work experiences, ensuring to detail any gaps longer than six months if applicable.
7. Answer all questions in the 'General Information' section related to Medicaid and Medicare participation, and provide any numbers associated with these programs.
8. Complete the 'Attestation/Confidential Questions' section carefully, providing truthful answers to ensure clarity on your professional history and any possible sanctions or investigations.
9. Review the 'Information Release/Acknowledgments' section, sign, and date the document ensuring every section is completed accurately before submission.
10. Finally, save the changes made to your application. You can download a copy of the completed form, print it, or share it through appropriate channels as instructed.

Take the next step by completing your ASH Network Participation Application online today.