Get Bronson Health Medical Staff/app Intake Form 2020-2025

Filling out the Bronson Health Medical Staff/APP Intake Form online is a straightforward process that allows healthcare providers to submit their information efficiently. This guide will help you navigate each section of the form, ensuring you provide all necessary details accurately.

Follow the steps to complete the form seamlessly.

1. Use the ‘Get Form’ button to obtain the Bronson Health Medical Staff/APP Intake Form and open it in your online editor.
2. Begin by entering your provider name and email address in the corresponding fields. Ensure both are correct to facilitate communication.
3. Fill in the provider alias if applicable, followed by your contact telephone number and specialty area.
4. Indicate your gender in the designated field, and provide the name of your supervising physician if you are an APP provider.
5. Select the appropriate service you are requesting by checking the box for initial application or any other relevant option. Complete the requested location portions, specifying your primary location and any additional locations.
6. Fill in the Bronson health or service group name, and specify your requested start date. Indicate whether you are seeking employment full-time, part-time, or on-call.
7. If applicable, provide details about any locum tenens company, including the company name and contact information.
8. Describe the services and clinical role you will be performing at Bronson in the provided space.
9. Complete the practice manager section with their contact details, ensuring to note any location updates if you are moving locations.
10. Enter your NPI and CAQH numbers in the specified fields, and provide the relevant usernames and passwords as needed.
11. Mention your tax ID and any payer enrollment specifics as required.
12. Finally, fill out the person completing the form section, including your date, phone number, and email address, and ensure you have the practice manager's approval.
13. Once all fields are completed, you can save your changes, download the form for your records, print it, or share it accordingly.

Complete your Bronson Health Medical Staff/APP Intake Form online today to ensure a smooth intake process.