Get Ihcp Ordering, Prescribing, Referring Provider Enrollment And Profile Maintenance Packet

This guide provides clear instructions on completing the IHCP Ordering, Prescribing, Referring Provider Enrollment And Profile Maintenance Packet online. Following these steps will ensure that you can efficiently manage your enrollment and updates to your provider profile.

Follow the steps to complete your packet online.

1. Press the ‘Get Form’ button to access the IHCP Ordering, Prescribing, Referring Provider Enrollment And Profile Maintenance Packet.
2. Select the appropriate purpose for your submission in Section I: Type of Request. Choose from New Enrollment, Profile Update, or Disenroll as applicable.
3. Complete Section II: Provider Information. Ensure you provide your National Provider Identifier (NPI), name, date of birth, and contact information accurately.
4. Access Section III: License/Certification Information. List all relevant professional licenses, ensuring that you provide correct license numbers and states of issuance.
5. For Section IV: Medical Specialties, designate your specialty from the provided options, ensuring that it reflects your qualifications.
6. Move to Section V: Final Adverse Legal Actions/Convictions. Indicate if you have faced any final adverse legal actions and provide the necessary details if applicable.
7. In Section VI: Provider Signature/Attestation, print your legal name, sign the document, and date it. Ensure all information provided is truthful and complete.
8. After completing the packet, carefully verify that all necessary information is filled out to avoid processing delays.
9. Save the completed packet, and print it for your records.
10. Mail the packet to the HP Provider Enrollment address provided to officially submit your enrollment or updates.

Start filling out the IHCP Ordering, Prescribing, Referring Provider Enrollment And Profile Maintenance Packet online today!