Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by filling in the Group Name (or Name of Practice) and Fed Tax ID # fields at the top of the form. Ensure accuracy, as this information is critical for payment processing.
3. Provide your Hospital Affiliation(s), Contact Name, and Email Address. This information helps maintain clear communication between you and the health plan.
4. Indicate the number of physicians within your practice. This field helps the health plan understand the scale of your services.
5. Complete the Service Location(s) section by filling in your primary address, including the suite number, city, state, zip code, and contact phone and fax numbers. Specify your office hours as well.
6. If applicable, fill out the secondary address and any additional service locations on a separate sheet, as indicated.
7. In the Billing Location section, repeat the process for your primary billing address and indicate if it is the same as your service location.
8. Answer questions related to e-prescribing and patient portal capabilities by checking ‘Yes’ or ‘No’ as appropriate.
9. Return all required documents, including the Provider Disclosure Information Form, Provider Information Form, a copy of your W-9, and the signed contract, as specified.
10. Review all inputted information for accuracy. Finally, save changes, download, print, or share the completed form as needed.

Ensure your accuracy by completing the MI McLaren Health Plan Provider Information Form online.