Get Tx Amerihealth Caritas Provider Data Intake Form 2017-2025

Completing the TX AmeriHealth Caritas Provider Data Intake Form online is a straightforward process designed to streamline information submission for healthcare providers. This guide will provide you with step-by-step instructions to ensure accurate and efficient form completion.

Follow the steps to successfully fill out the form.

1. Click ‘Get Form’ button to access the form and launch it in your preferred document editor.
2. Begin by selecting your provider type: Primary care provider, Specialist, or Behavioral health. This selection is crucial as it categorizes your service type.
3. Enter the entity name as it is recorded on your W9 form. If applicable, include the independent practice association (IPA) name.
4. If you are doing business under a different name, provide that information in the designated field.
5. Input your Provider TIN/EIN number in the specified field using nine characters exactly.
6. Fill out the primary contact name and provide the primary contact email address.
7. Complete the group name field, making sure it accurately reflects how you prefer to be listed in the provider directory.
8. Provide your street address, including building or suite number, city, state, and ZIP code along with the four additional digits.
9. Enter your taxonomy code and group NPI in the relevant sections.
10. List each practice location under the main practice location, and if you have multiple locations, continue to fill out practice locations 2 through 5.
11. For each practitioner roster, include the first name, last name, middle initial, degree, specialty, CAQH registration number, taxonomy code, and Medicaid ID/NPI if applicable.
12. Indicate if the practitioner is a primary care provider by selecting 'Yes' or 'No' in the appropriate field.
13. If you need more space, feel free to attach an additional document with your completion.
14. Once all fields are filled out, you can save your changes, download, print, or share the form as necessary.

Complete your form online today for a smoother enrollment process.