Follow the steps to effectively complete the application.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by filling out the provider information section, including your first name, last name, group or organization name, email address, tax ID, national provider identifier (NPI), and license. Be sure all details are accurate.
3. Indicate your provider type by selecting the appropriate option: primary care, specialist, or ancillary.
4. Next, provide your location information. Include your street address, suite number (if applicable), city, state, and zip code. Additionally, enter your phone number and fax number for contact purposes.
5. In the staff user information section, fill in the first name, last name, title, email address, and a phone number if it differs from your own.
6. Review the agreement terms listed under the signing section. These terms pertain to HIPAA compliance and security responsibilities. Ensure you understand and agree to all conditions before proceeding.
7. Print your name, title, and sign the form where indicated. Include the date of submission to finalize your application.
8. Finally, to complete your submission, save any changes made to the form, and choose whether to download, print, or share the completed form for your records.

Start completing your application form online today for a seamless experience.