Get Ppac Phys Addendum For Enrollment As A Specialist - Form #406201

The PPAC Phys Addendum for Enrollment as a Specialist - Form #406201 is a vital document for healthcare providers seeking to enroll in the Medicaid Preferred Physicians and Children Program in New York. This guide provides clear, step-by-step instructions on how to complete this form online successfully.

Follow the steps to fill out the PPAC Phys Addendum for Enrollment As A Specialist online.

1. Click ‘Get Form’ button to obtain the form and open it in a digital editing tool.
2. Begin by accurately entering your identifying information in Section A. Fill in your last name, first name, middle initial, license number, and the state. If you are an enrolled Medicaid provider, also provide your MMIS number and National Provider Identifier (NPI).
3. Proceed to Section B, titled Practice Information. Here, indicate if you employ any nurse practitioners or physician assistants by listing their names and license numbers. If more space is needed, attach additional pages.
4. In Section C, check one box regarding your active hospital admitting privilege. If you have an active privilege, include a copy of your hospital appointment letter. If you do not, state the circumstances for consideration by completing Section E for exceptions.
5. Section D is dedicated to Assurances. Read each assurance carefully and acknowledge your commitment to provide comprehensive care to Medicaid patients, maintain certain standards, and coordinate care. Lastly, print your name, sign, and date at the end of this section.
6. If applicable, complete Section E to request an exception. Fill in the required information and check the relevant boxes to indicate the documentation you are attaching to support your request.
7. Once all sections are thoroughly completed with the necessary information and attachments, review the entire form for accuracy and completeness.
8. Finally, save changes to your document, then download, print, or share the completed form according to your requirement.

Start filling out the PPAC Phys Addendum Form online now to ensure a smooth registration process.