Loading
Form preview picture

Get CareSource CS-0208c 2016-2024

CareSource Provider/Group Hierarchy Change Request Form Date PR Rep Adding a Provider Deleting a Provider Changing Demographics Ex. Return to Providermaintenance caresource. com OR Fax to 937 396-3076 Revision Date 05/19/2016 CS-0208c Age Restrictions 18 yrs older Race/ Ethnicity Gender. Practice location change specialty change NPI/Phone/Fax Change Capacity Restrictions Details regarding any of the above changes can be placed in NOTES section on the last page Group IRS Name Group DBA Group TIN Group NPI Group Medicare Medicaid-OH Just4Me-WV Product MyCare-OH Just4Me-OH MedicareAdv-OH CTP-OH Just4Me-KY Just4Me-IN Office Contact Contact Name Contact Phone Contact Email Please indicate if you are FQHC RHC QFPP CMHC Contract Signatory Name Individual who is legally authorized to sign documents Signatory Title Signatory Email Address Remit Name Remit Mailing Same as above Contractual Updates Street City State Zip Provider Information Name Deg. ST County Phone Fax NPI John Doe SAMPLE MD 123 Main St Anywhere OH 45123 Greene 937-555-1212 1231231291 CAQH Medicare Specialty PCP Y/N If Y Capacity 1234567 FP Y Race/Ethnicity Asian Black or African American* Hispanic or Latino American Indian White Other Choose Not to Answer Notes Please insert rows if more lines are needed* Important Please include W-9 and ensure all CAQH applications are updated and accurate to ensure timely processing of providers. Practice location change specialty change NPI/Phone/Fax Change Capacity Restrictions Details regarding any of the above changes can be placed in NOTES section on the last page Group IRS Name Group DBA Group TIN Group NPI Group Medicare Medicaid-OH Just4Me-WV Product MyCare-OH Just4Me-OH MedicareAdv-OH CTP-OH Just4Me-KY Just4Me-IN Office Contact Contact Name Contact Phone Contact Email Please indicate if you are FQHC RHC QFPP CMHC Contract Signatory Name Individual who is legally authorized to sign documents Signatory Title Signatory Email Address Remit Name Remit Mailing Same as above Contractual Updates Street City State Zip Provider Information Name Deg. ST County Phone Fax NPI John Doe SAMPLE MD 123 Main St Anywhere OH 45123 Greene 937-555-1212 1231231291 CAQH Medicare Specialty PCP Y/N If Y Capacity 1234567 FP Y Race/Ethnicity Asian Black or African American* Hispanic or Latino American Indian White Other Choose Not to Answer Notes Please insert rows if more lines are needed* Important Please include W-9 and ensure all CAQH applications are updated and accurate to ensure timely processing of providers. .

How It Works

caresource hierarchy form rating
4.8Satisfied
294 votes

Tips on how to fill out, edit and sign Caresource pdf online

How to fill out and sign Clbc assessor form online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

The days of distressing complex legal and tax documents are over. With US Legal Forms the procedure of creating legal documents is anxiety-free. The leading editor is right close at hand supplying you with an array of advantageous instruments for submitting a CareSource CS-0208c. The following tips, in addition to the editor will guide you through the entire procedure.

  1. Hit the orange Get Form option to start filling out.
  2. Switch on the Wizard mode in the top toolbar to acquire more recommendations.
  3. Fill in each fillable field.
  4. Ensure the details you fill in CareSource CS-0208c is up-to-date and accurate.
  5. Add the date to the form using the Date option.
  6. Select the Sign icon and create an electronic signature. Feel free to use 3 available options; typing, drawing, or capturing one.
  7. Re-check every area has been filled in correctly.
  8. Select Done in the top right corne to export the file. There are many options for receiving the doc. An attachment in an email or through the mail as a hard copy, as an instant download.

We make completing any CareSource CS-0208c much easier. Get started now!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing caresource change

Go through the most up-to-date methods in digital administration. Fill out Form within a few minutes using our simple step-by-step video guidelines.

Caresource ohio pa form FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to CareSource CS-0208c

  • FQHC
  • MyCare
  • QFPP
  • CMHC
  • CTP
  • dba
  • Providermaintenancecaresource
  • 0208c
  • PCP
  • greene
  • RHC
  • deg
  • CareSource
  • yrs
  • Signatory
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.