Get Magnolia Health Initial Contract Request Form 2015-2025

The Magnolia Health Initial Contract Request Form is a crucial document for initiating a new group contract. This guide will help you navigate the form's sections and fields efficiently, ensuring you complete it correctly and effectively.

Follow the steps to fill out the form online successfully.

1. Press the ‘Get Form’ button to access the Magnolia Health Initial Contract Request Form and open it in your selected editor.
2. Indicate your provider type by selecting all applicable options from the list provided. Options include medical group, hospital, solo practitioner, and others.
3. Fill out the group information section. Include the group name, primary physical address, city/state/zip code, and phone number.
4. Provide details for the administrative contact person, including their title, e-mail address, and fax number.
5. Complete the hours of operation section by detailing each day's hours in the respective spaces.
6. Specify your county, group Medicaid number, Medicare number, and taxpayer identification number (TIN).
7. Input the billing national provider identifier (NPI) number for your group.
8. If there is a different credentialing contact person, provide their name, phone number, and email address.
9. Answer the questions regarding compliance with Americans with Disabilities Act (ADA) requirements and language proficiency of your practitioners.
10. Include any additional notes in the designated space to clarify any special requirements or details.
11. Once the form is fully completed, save the changes, download the document, or print and share as necessary.

Complete your Magnolia Health Initial Contract Request Form online today.