Get Wa Amerigroup Wapec-0003-11

Filling out the WA Amerigroup WAPEC-0003-11 form online is an essential step for providers looking to establish or update their information with Amerigroup Washington, Inc. This guide will walk you through the necessary steps to complete the form comprehensively and accurately.

Follow the steps to fill out the WA Amerigroup WAPEC-0003-11 form online

1. Press the ‘Get Form’ button to access the form and open it in the designated form editor.
2. Begin with Section I – Provider Entity Information. Enter the legal business name and any 'doing business as' name, along with the tax ID number.
3. Fill in the primary address details, including the city, state, ZIP code, and county.
4. Indicate the provider type by selecting a number (1 for practitioner, 2 for hospital, 3 for pharmacy, 4 for clinic, 9 for other) and provide the business telephone number.
5. Provide the provider contact person name along with their contact phone number and fax number.
6. Enter the state license number, the state that issued the license, as well as the Medicaid number, NPI number, and NPI taxonomy.
7. Answer whether your group has a website; if so, enter the website address.
8. Proceed to Section II – Practitioner Information and Professional IDs. Enter the last name and first name of the practitioner, as well as any applicable state license numbers and Medicaid numbers.
9. Complete the middle initial field if applicable, and include the NPI number and taxonomy.
10. If applicable, insert the Council for Affordable Quality Healthcare (CAQH) ID.
11. Move to Section III – Professional/Medical Specialty information. Enter the primary specialty and any secondary specialties, along with the professional degree.
12. Specify any limits on the services you provide, and list any languages spoken other than English.
13. Indicate whether the provider offers obstetrical and pediatric care by answering yes or no. Also, specify if the provider provides EPSDT services.
14. Clarify the provider's status as PCP only, SCP only, or both, and check if the PCP panel status is open or closed. Indicate whether you accept current patients only.
15. Finally, review all entered information for accuracy. If needed, use N/A for any items that are not applicable. For group practices, refer to the additional instructions provided.
16. Once all sections are complete, save your changes, download a copy, print the form if necessary, or share it as required.

Take action now and complete the WA Amerigroup WAPEC-0003-11 form online to ensure your provider information is current and accurate.