Get Adult And Child Protective Service Central Registry Screening ... - Dhhs

This guide is designed to assist users in completing the Adult and Child Protective Service Central Registry Screening form online. Follow these clear and concise steps to ensure that you provide all necessary information accurately.

Follow the steps to fill out the form successfully.

1. Press the ‘Get Form’ button to access the form, opening it in your preferred digital interface.
2. Begin by entering your contact information. Fill in your first name, middle initial, last name, suffix, phone number (including area code), job title, and email address.
3. Proceed to the provider information section. Again, provide your first name, middle initial, last name, suffix, and the complete address including city, state, and zip code. Input your National Provider Identifier (NPI) number and, if not enrolled in Medicaid, include your license number.
4. For the CMS EHR certification number, list all relevant Certification numbers associated with your EHR system.
5. Indicate whether you wish to reassign your incentive payment to a different payee by selecting 'Yes' or 'No.' If 'Yes,' provide the payee’s name, address, and practice NPI.
6. Complete the eligibility information by selecting your provider type. Answer if you are a pediatrician and indicate if you practice predominantly in a hospital setting.
7. If applicable, provide details about any sanctions with Medicare or Medicaid by selecting 'Yes' or 'No.' If 'Yes,' specify the states.
8. Fill out patient volume information, including the total number of Medicaid patient encounters during the specified reporting period. Document any total patient encounters and indicate if you practice in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC).
9. Review and acknowledge the terms of attestation and agreement, ensuring all commitments are understood and accepted.
10. Finally, print your name, sign the form, and date it. Ensure all information is accurate before submitting the document.

Complete your Adult and Child Protective Service Central Registry Screening form online today to ensure your application is processed efficiently.