Get Pa Consolidated Community Reporting Initiative Provider Enrollment Application Short Form 2019-2025

Filling out the PA Consolidated Community Reporting Initiative Provider Enrollment Application Short Form is an essential step for providers seeking enrollment. This guide will walk you through the process, ensuring you complete each section accurately and efficiently.

Follow the steps to successfully complete your application.

1. Click the ‘Get Form’ button to access the enrollment application and open it in your editor.
2. In the first section labeled 'Action Requested,' enter the effective date of your enrollment and your 13-digit PROMISe™ provider ID number.
3. For the 'Enrollee’s Name' section, list the applicant’s name and date of birth (individuals only). If you operate under a fictitious business name, attach the necessary documentation.
4. Input the provider type number and provide a brief description of the type you are enrolling.
5. In the 'Provider Specialty Number and Description' section, enter the specialty number and description relevant to your services.
6. For 'License Number,' input your professional or state license number, if it applies to your situation.
7. In 'Physical Service Location,' provide the actual address where services will take place. Note that a Post Office Box is not an acceptable address.
8. Complete the 'Mail to Information' section with the address for receiving correspondence related to your enrollment.
9. Finally, sign and date the application, print your name, and provide your telephone number. The signature must belong to the individual applying or an authorized representative.
10. Submit the completed application to the appropriate county by mail or email, ensuring you also forward the required documentation.

Take the next step and complete your application online today.