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Get Anthem Provider Application For Temporary Participation
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How to fill out the Anthem Provider Application for Temporary Participation online
Filling out the Anthem Provider Application for Temporary Participation is an essential step for physicians seeking temporary roles in Maine. This guide provides clear, step-by-step instructions to help you complete the application accurately and efficiently online.
Follow the steps to successfully complete your application online:
- Click 'Get Form' button to obtain the form and access it in the editor.
- Provide your personal information, including last name, first name, middle name, date of birth, and gender. Make sure that all information is accurate.
- Fill in your office contact person's information, including their phone number.
- Enter your National Provider ID (NPI) and Taxonomy Code in the designated fields.
- Specify the dates of your office coverage. Ensure that the dates do not exceed six months.
- Input your primary office location, billing location, and mail/correspondence address along with phone and fax numbers.
- Identify your group, partnership, or corporation name, as well as your federal tax ID number.
- Select your specialty from the available options.
- Acknowledge that you are applying as a temporary provider for up to six months and agree to abide by the terms and conditions defined in the application.
- Explain briefly the circumstances that require hiring a temporary provider.
- Provide your printed name, signature, and date at the end of the application.
- Complete the IRS Form W-9 by entering your taxpayer identification number and personal details as instructed.
- Once all sections are completed, review your entries for correctness before saving changes, downloading, printing, or sharing the form.
Get started and complete your documents online today!
The PMF, or Provider Medical Form, from Anthem Blue Cross is an essential document that healthcare providers must complete. It verifies the professional credentials of healthcare providers and expedites their application process. Submitting this form can be an important step when working with Anthem, especially for those interested in the Anthem Provider Application for Temporary Participation.
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