Get Facility Initial Application - Coventry Health Care Of Kansas

This guide provides a comprehensive overview of how to complete the Facility Initial Application for Coventry Health Care Of Kansas. By following these clear instructions, users can efficiently fill out the form online, ensuring that all required information is accurately provided.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the Facility Initial Application and open it in the online editor.
2. Begin with the Application Checklist. Ensure you have all necessary documents ready to attach, such as your state license, professional liability insurance, and accreditation letters.
3. Fill out the Facility Type section by selecting the appropriate facility type options, such as 'Audiology' or 'Hospital'.
4. In the General Information section, provide the legal and DBA names, addresses, contact information, Federal Tax ID number, and Facility NPI number.
5. Complete the Billing Information, Credentialing Office, and Address sections by listing relevant contacts and their details.
6. Enter Ownership and Control details, including the owner's name and address.
7. Complete the Services section, indicating operational details such as emergency services, accessibility, and hours of operation.
8. Fill out the Licensure/DEA section by providing the state license number(s) and expiration dates as required.
9. Attach necessary accreditation and certification documents in the Accreditation/Certification section.
10. Complete the Professional Liability Insurance section by entering your policy number, carrier name, coverage types, and dates.
11. Respond to the Confidential Additional Information questions and provide explanations for any 'Yes' responses.
12. Finalize the application by certifying the truthfulness of the information provided, then sign and date the form.
13. After completing the form, save your changes. You may choose to download, print, or share the application as needed.

Complete your application online today and ensure all components are accurately filled out.