1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Fill in the facility information section, including the legal business name, practice name, tax ID number, NPI number, and Medicaid ID number.
3. Indicate whether the provider is enrolled in the Community Health Automated Medicaid Processing System (CHAMPS) and provide the effective and end dates if applicable.
4. Complete the accreditation and licensing section by attaching relevant documents, such as the current state license, Medicare number, and DEA registration if required.
5. Fill out the insurance details, providing information about both general and professional liability coverage, along with copies of the insurance certificates.
6. Respond to the disclosure questions regarding the facility and provider background; ensure to provide detailed explanations for any affirmative answers.
7. Review the application for completeness and accuracy; gather any additional documents mentioned in the checklist.
8. Once the form is fully completed, save your changes and download a copy for your records. You can then print or share the form as required.

Complete your MI AmeriHealth Caritas Application Checklist online today to ensure a smooth credentialing process.