Get Caresource Ga-p-0548 2018-2025

Filling out the CareSource GA-P-0548 form online is a straightforward process. This guide will provide you with clear, step-by-step instructions to ensure you accurately complete the form and submit it effectively.

Follow the steps to complete the online form successfully.

1. Click ‘Get Form’ button to initiate the process and access the form for editing.
2. Enter the date in the designated space provided at the top of the form.
3. Identify the PR representative by entering their name in the appropriate field.
4. Provide the group IRS name. Make sure this matches line 1 on the W-9 form.
5. Select the type of change you are making by checking the relevant boxes: adding a provider, deleting a provider, changing demographics, or changing the IRS name.
6. Fill in the group DBA, TIN, NPI, and Medicaid number as required. Note that a valid Medicaid number is necessary for any Medicaid products.
7. Indicate the product type by selecting 'Medicaid – GA' in the relevant field.
8. If applicable, add the provider group website, office contact name, contact phone, and contact email under the contact information section.
9. Indicate your role by checking if you are a contract signatory. Fill in the signatory name, title, and email address of the person authorized to sign documents.
10. Complete the remit name and address information including street address, city, state, and zip code. You can specify if this is the same as the above section.
11. Provide any necessary details for contractual updates, ensuring consistency with the previous section.
12. Fill in the provider details for each provider. Include their degree, telemedicine services, presentation site, contact information, board certifications, specialties, and any age restrictions.
13. Review the race/ethnicity, CAQH number, and any additional languages or competencies for each provider as necessary.
14. If there are additional providers, use the option to insert rows for more lines to ensure all necessary information is captured.
15. In the notes section, provide any additional relevant details regarding the changes requested.
16. Once all sections are filled out accurately, save your changes and choose to download, print, or share the completed form as needed.

Complete your CareSource GA-P-0548 form online today to ensure efficient processing.