Get Avmed Mp-5655 2022-2025

This guide provides step-by-step instructions on how to complete the AvMed MP-5655 form for new providers. Whether you are familiar with digital forms or filling one out for the first time, this guide will support you in navigating the online process effectively.

Follow the steps to complete the AvMed MP-5655 form efficiently.

1. Press the ‘Get Form’ button to access the AvMed MP-5655 form and open it in your digital editor.
2. Begin by filling out your personal information. This includes your first name, middle initial, last name, and any relevant degrees. Ensure that your entries are clear and legible.
3. Provide your Tax Identification Number (Tax ID#) and your National Provider Identifier (NPI) number, indicating whether you are representing a group practice or operating as an individual practitioner.
4. Enter your facility name (if applicable) and the primary office address, including city, county, and zip code. Specify your office hours for patient access.
5. Fill in the contact information. This should include a contact person, a phone number, a fax number, and your email address.
6. Select your provider type/description by checking the appropriate box, such as primary care/specialist, group practice, or solo practitioner. Also, indicate your specialty and board certification status.
7. If applicable, provide information about your primary hospital affiliation. Include the electronic health records (EHR/EMR) vendor if you utilize such systems.
8. Include your CAQH ID number if available, and list any other hospital affiliations and partners involved in your practice.
9. Review the completed form for accuracy and clarity. It is important to ensure that all sections are filled out correctly.
10. Once you have filled out the form, save your changes. You can then download, print, or share the form as needed, along with a completed and signed W-9 when submitting.

Get started now to complete the AvMed MP-5655 form online!