Get Application For Provider Panel Membership - Nyc . Gov - Nyc

Filling out the application for provider panel membership is a crucial step for orthodontists seeking to participate in the New York City Orthodontic Rehabilitation Program. This guide will provide clear and supportive instructions to help you successfully complete the application online.

Follow the steps to fill out the application effectively.

1. Click ‘Get Form’ button to access the application form and open it in your desired editor.
2. In the first section, enter the application date and your full name. Make sure to use your legal name as per your official documents.
3. Provide your home address, including street, city, state, and zip code, along with your home telephone number.
4. For the education section, list the dental school you attended and the date you graduated. If you have completed any postgraduate studies, include the name of the institution, the dates of attendance, and the degree or certificate attained.
5. Fill out the details of your orthodontic office, including the name, address, phone number, days and hours of coverage, email address, and fax number.
6. If applicable, include any other New York City practice locations where children will be treated, specifying address, phone number, and hours of coverage.
7. Enter your New York State dental license number, New York State Medicaid specialty provider number, and your Social Security number for verification purposes.
8. Refer to the eligibility requirements section and ensure you meet all criteria. Gather necessary documents such as your current NYS dental license, degree or certification, board certification (if applicable), and an executed commercial office lease.
9. Complete the affidavit section where you will sign and date the application, confirming the accuracy of your information.
10. Once all sections are filled out accurately, save any changes made to the form. You may also download, print, or share the completed application as required.

Take the next step in your professional journey by completing the application online today.