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Get Nc Amerihealth Caritas Ancillary Data Intake Form 2019-2025
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How to fill out the NC AmeriHealth Caritas Ancillary Data Intake Form online
Filling out the NC AmeriHealth Caritas Ancillary Data Intake Form online may seem daunting, but this guide will provide you with clear, step-by-step instructions. By following the directions provided, you will ensure that all necessary information is accurately captured.
Follow the steps to accurately complete the intake form.
- Click ‘Get Form’ button to access the NC AmeriHealth Caritas Ancillary Data Intake Form and open it in your preferred editing tool.
- In Section 1, begin by entering the provider entity name as it appears on the W9. If a IPA name applies, provide that information as well. Select the billing type and, if applicable, the name you do business as.
- In Section 2, provide information for all practice locations. Complete the category for each location, including group/facility names, address details, and primary contact information including telephone and fax numbers.
- Section 3 requires you to indicate the ADA compliance for each location. You will check appropriate boxes for compliance categories related to access for various disabilities.
- In Section 4, specify which services are provided at each location, including options like home care, physical therapy, and various rehabilitative services. For each service, check the relevant location numbers.
- After completing all sections of the form, review your entries for accuracy. You may then save your changes, download the form for your records, or print it out for submission.
Once you are ready, complete the form online to ensure efficient processing.
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