Follow the steps to complete the Gateway Health Provider Data Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date on which you are completing the form at the designated field.
3. Specify your primary practice state in the appropriate section.
4. Indicate your wish to participate with Medicaid and enter your Medicaid number and effective date in the provided fields.
5. If applicable, specify your participation with Medicare by entering the Medicare number and effective date.
6. Fill in your last name, first name, and middle initial in the specified sections.
7. Provide your primary telephone number and primary fax number in their respective fields.
8. Complete the address section, entering your primary practice and credentialing addresses, including street address, suite number (if any), city, state, and zip code.
9. Select your provider type (e.g., MD, DO, DC, DDS, DMD, DPM) by checking the relevant option.
10. Indicate your county of practice and provide your NPI number, marking whether you have one.
11. If you have an NPI, confirm board certification by filling in the board name if applicable.
12. Indicate whether you are registered with CAQH by selecting yes or no, and provide your CAQH Provider ID if applicable.
13. Enter your social security number, date of birth, state license number, and the licensed state.
14. Select your application type (Primary Care Provider, Specialist, or Allied Health Professional) by checking the corresponding box.
15. Specify your specialty and indicate your board certification status.
16. Review the information carefully and ensure all fields are accurately filled out.
17. Once completed, save your changes, download a copy for your records, and share it with Gateway Health by faxing it to the provided number.

Begin completing your Gateway Health Provider Data Form online today!