Get Tx Amerihealth Caritas Provider Data Intake Form 2018-2025

Completing the TX AmeriHealth Caritas Provider Data Intake Form online is an essential step for providing necessary information to the organization. This guide will walk you through each section and field of the form so you can accurately fill it out with confidence.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to access the TX AmeriHealth Caritas Provider Data Intake Form and open it in your chosen online platform.
2. In Section 1, enter the entity name as it appears on the W9 form. Select the appropriate category such as PCP, Specialist, IPA name, or others. Provide additional details as required, including the provider TIN/EIN number and primary contact information.
3. Move to Section 2 where you will detail all locations affiliated with your practice. Complete the fields for group name, address, taxonomy code, and obtain the respective NPI and Medicaid ID for each practice location.
4. In Section 3, specify the number of practitioners for each provider type for both adult and child categories. Ensure to include all relevant specialties available at your practice.
5. Proceed to Section 4; list services provided at each location from the options given. Use the ‘Additional location information/notes’ section for any specific instructions related to each service.
6. In Section 5, complete the practitioner roster with necessary details such as the first name, last name, qualification, specialty, and registration numbers for each practitioner.
7. Once all sections have been completed, review the form for accuracy and clarity. When satisfied, you can save changes, download a copy, or choose to print or share the form for submission.

Begin completing the document online for efficient and accurate registration.