Get Group Membership Authorization Form

Filling out the Group Membership Authorization Form is an essential process for providers submitting Medicaid claims under a group number. This guide will help you navigate the online form efficiently and ensure all necessary information is accurately provided.

Follow the steps to fill out the Group Membership Authorization Form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your Medicaid Provider ID or Application Tracking Number (ATN) at the top of the form. This information is crucial for processing your submission.
3. Next, provide your Provider Name. Please print it clearly to avoid any discrepancies.
4. In the following section, fill out the Group Name, ensuring it matches exactly with the group under which you are submitting claims.
5. If your group's provider number is pending, include the Group Tax ID. This information is required to link your submission with their pending application.
6. Enter the Group Medicaid Provider ID if available. If not, this section can be left blank while your group application is pending.
7. Indicate the Effective Date. If the group application is still pending, you may leave this field blank.
8. Review the authorization statement carefully. By signing, you confirm that you allow the group providers listed to submit claims on your behalf. Make sure you understand the terms.
9. Finally, provide your signature and the date of signing in the designated areas. This completes the form.
10. Once all fields are correctly filled, save changes, and you may choose to download, print, or share the completed form as needed.

Complete your Group Membership Authorization Form online today to streamline your Medicaid claims process.