Please Submit Current W-9 Last Name First Name Practice/Group Name Employer Name (if applicable) Federal Tax ID Number License Number Do you bill under the group? YES or MI Group NPI # (please circle one) NPI# (if applicable) Degree DEA Number Date of Birth NO In the following section, please list addresses as you want them to appear in the Provider Directory. These would include addresses where you typically see patients. Primary Office Address Street Suite No.
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How to fill out the MI McLaren Health Plan Provider Information Form online
Filling out the MI McLaren Health Plan Provider Information Form online is a straightforward process that ensures healthcare providers can supply their necessary information efficiently. This guide provides step-by-step instructions to help you complete the form accurately.
Follow the steps to effectively complete the provider information form.
- Click the ‘Get Form’ button to access the MI McLaren Health Plan Provider Information Form and open it for completion.
- Begin by filling in the general information section. Enter your CAQH number, indicate your board certification status, and provide your social security number. Make sure to submit a current W-9 along with the form.
- Fill in your personal details, including your last name, first name, practice or group name, and employer name if applicable. Additionally, provide your federal tax ID number, license number, and DEA number as required.
- Specify if you bill under a group by selecting 'Yes' or 'No,' and include the group NPI number if relevant. Provide your degree and date of birth.
- List your primary office address, including street, suite number, city, state, zip, county, telephone, and fax numbers. Repeat this for your secondary office address if applicable.
- Indicate the billing remittance address if it differs from the primary address. Include the billing company name, address details, and contact information.
- Choose your medical specialty by checking the appropriate box. You may select more than one designation that applies to your practice.
- Indicate whether you are accepting new patients by selecting 'Yes' or 'No.'
- List your hospital affiliations, including the names of hospitals where you have admitting privileges and their status.
- Provide contact information for an office contact person who can provide further details if needed.
- Complete the provider certification section by certifying that your provided information is true and correct. Print your name, sign, and date the form.
- Finally, save changes to the form, and you have the options to download, print, or share the completed document as necessary.
Complete your MI McLaren Health Plan Provider Information Form online today for a seamless submission process.
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