Follow the steps to successfully complete your application.

1. Click the ‘Get Form’ button to download the application form and open it in the online editor.
2. Begin by filling out the 'Provider Identification' section. Enter the legal business name, doing business as (DBA) name if applicable, and provide the contact details for the credentialing contact, including email and phone number.
3. In the 'Location/Service Address to be Credentialed' section, input the address details for the facility. Make sure to indicate if any locations have unique identifiers, such as a license number or National Provider Identifier (NPI).
4. Complete the 'Primary Office Hours' section by indicating staff availability for each day of the week. Specify after-hours coverage if applicable.
5. Fill out the 'Patient Population Served' details by checking all applicable age groups and services offered. Provide any limitations as required.
6. In the 'Licensure & Certificates' section, list the types of licenses held, their issuance and expiration dates, and attach copies of required documentation.
7. Provide information about '(General and Professional) Liability Insurance.' Include details about the current carrier, policy numbers, coverage type, and attach the insurance certificate.
8. Address the 'Professional Disclosure Questions' honestly. For any 'Yes' responses, include a detailed explanation on a separate sheet.
9. Review the 'Attestation Consent and Release' section. Ensure you understand and agree to all terms before signing this section electronically.
10. Finally, verify that all necessary enclosures are attached as specified at the end of the application. Submit your completed application online after all sections are filled out and verified.

Begin the process of completing your Facility/Ancillary/Long-term Care Provider Credentialing Application online today to ensure all necessary details are submitted accurately.