Get Pro Ovider I Informa Ation Fo Orm

Filling out the Pro Provider Information Form online is an important step for healthcare providers wishing to work with CenCal Health. This guide provides you with clear instructions on each section of the form, ensuring that your submission is accurate and complete.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by filling out the Provider Name and Contact Information section. Ensure you input the legal business name, provider title, office phone, email, and mailing address accurately.
3. Proceed to the Billing Information section. Indicate how you will be billing CenCal Health, including the billing contact person's information if applicable.
4. Complete the Staff Information section by providing details about your office manager and any necessary contacts for referral authorization forms.
5. In the Provider Credentials & Identification Numbers section, enter your National Provider Identifier (NPI), Tax ID, and other critical IDs as required.
6. Fill out the Group Contracting/Group Changes section if you are part of a provider group. Include relevant group identifiers and rendering provider names.
7. Complete the Hospital Affiliations section by listing any hospitals you are affiliated with.
8. Indicate your Office Hours clearly to inform patients of your availability.
9. Address accessibility aspects in the Accessibility section to ensure your practice accommodates individuals with disabilities.
10. Answer the questions in the Questionnaire section to provide additional information about your practice’s services.
11. For Primary Care Physicians, fill out the specific sections related to your services, including after-hours care.
12. Use the Additional Information section to share any pertinent comments about your practice.
13. Review all the information provided for accuracy before submitting.
14. Once all sections have been completed and reviewed, save your changes. You can then download, print, or share the completed form as necessary.

Complete your Pro Provider Information Form online today and ensure your practice is recognized by CenCal Health.