Get Cro Provider Enrollment Form - Eikids

The CRO Provider Enrollment Form - EiKids is a crucial document for providers seeking to enroll in the early intervention services program in Indiana. This guide will walk you through each section of the form, providing clear instructions on how to fill it out effectively and completely.

Follow the steps to complete the enrollment form accurately.

1. Click the ‘Get Form’ button to obtain the CRO Provider Enrollment Form - EiKids and open it in your preferred online editor for processing.
2. Begin with the provider information section. Enter your Federal Tax ID or Social Security Number, followed by the payee or facility name. Fill in your first name, middle initial (if applicable), and last name.
3. Next, provide your Member NPI (National Provider Identifier) and the site address where services will be performed. Complete the city, state, and zip code fields along with your email and phone number, ensuring all details are accurate.
4. For the billing information section, indicate if this is new information or a change of information, and specify what type of changes are being made. If dis-enrolling, include the last date of work.
5. Continue with the provider matrix information. Input the name on your license, type of professional license, license number, state of issue, expiration date, name on your degree, type of degree, description of degree, and the institution where you obtained it.
6. In the early intervention discipline section, select your specialty from the list provided. Ensure you choose the appropriate designation for your enrollment.
7. If you are requesting changes in your status, be aware to include any supporting documentation required along with the completed form.
8. Finally, after completing all sections, ensure you sign and date the form. Review the entire document for accuracy before submission.
9. You can save your changes, download, print, or share the completed form as needed.

Complete your enrollment form online today to ensure you are listed as a provider in the Service Matrix.