Get Caresource Oh-p-540b

Filling out the CareSource OH-P-540b form is essential for managing provider and group changes efficiently. This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately online.

Follow the steps to fill out the CareSource OH-P-540b form effectively.

1. Click the ‘Get Form’ button to acquire the form and open it in your online editor.
2. Indicate whether you are adding or deleting a provider, or if there is a demographic change. Select the appropriate checkbox: 'Add a Provider', 'Delete a Provider', or 'Demographic Change'.
3. Provide the Group IRS Name, Group DBA, Group TIN, Group NPI, Group Medicare Number, and Group Medicaid Number in the designated fields.
4. Select the relevant products offered, whether it is Medicaid only, SNP only, or multiple products, by checking the appropriate box.
5. Fill in the Office Contact information, including Contact Name, Contact Phone, and Contact Email.
6. In the Contract section, provide the Signatory Name, Signatory Title, and Signatory Email.
7. Complete the address details for Remit Name and Mailing Address. Include the street, city, state, and zip for each address mentioned.
8. Enter the Provider Information section with details such as Name, Street Address, City, State/County, Zip, Phone, Fax, NPI Number, CAQH Number, Medicaid Number, Medicare Number, and Specialty.
9. Use the notes section on Page 2 to add any additional details about the changes you are making.
10. Ensure to attach the W-9 and confirm that all CAQH applications are up-to-date for timely processing.
11. Once the form is complete, you can save your changes, download, print, or share the form as needed.

Take the next step and complete your CareSource OH-P-540b form online today.