Get Namci Initial Provider Application. Namci Provider Application

This guide provides a comprehensive overview of how to accurately complete the NAMCI Initial Provider Application. By following these clear instructions, you can ensure that your application is filled out completely and correctly.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to retrieve the NAMCI Initial Provider Application and open it for editing.
2. Begin by entering your personal information, including your last name, first name, middle name, and date of birth. Ensure that you fill in the fields accurately as this data is crucial for identification.
3. Provide your individual NPI and group NPI if applicable. This identification number is necessary for your participation as a provider.
4. Input your practice name, hours of operation, and primary office address. Ensure that the address is complete with street, city, state, and ZIP code.
5. Indicate whether you are board certified and, if so, provide the year of certification. If not certified, specify if you are eligible to take a board examination.
6. Input your contact information, including a phone number and fax number. This information will be used for communication regarding your application.
7. Fill out sections related to your educational background, including details of institutions attended, degrees earned, and any internships or residencies completed.
8. Provide information regarding your professional liability insurance, including the name of the carrier and whether you are accepting new patients.
9. Respond to the confidential questions regarding malpractice, physical or mental conditions affecting your practice, and any legal issues you may have encountered.
10. Review your application for accuracy and completeness. Attach any necessary explanatory statements, particularly in response to the confidential questions.
11. Finally, sign and date the application before submitting it. You can save changes, download, print, or share the completed application as needed.

Start your application process online today and ensure all required information is submitted efficiently.