Get the free CONNECTICARE PRACTITIONER DATA FORM - ynhh

Print Form CREDENTIALING DATA FORM Date: All Applicants must Complete & Submit this form, and Attach a W-9 Form to begin the credentialing process This form and W9 may be faxed to 860-674-2849 Thank

How to fill out connecticare practitioner data form

How to fill out the Connecticare practitioner data form:

1. Start by downloading the Connecticare practitioner data form from their official website.
2. Fill in your personal information, including your name, address, phone number, and email address.
3. Provide your professional information, such as your specialty, medical school attended, and board certifications.
4. Indicate your practice information, including the name of your practice, address, phone number, and email address.
5. Include the names and titles of other providers in your practice, if applicable.
6. Provide information about the facilities where you practice, including their names, addresses, and phone numbers.
7. Detail your hospital affiliations, if any, by providing the names, addresses, and phone numbers of the hospitals.
8. Fill in your insurance participation information, including the names of the insurance plans you accept and their corresponding identification numbers.
9. Attach any necessary supporting documentation, such as copies of your state license, DEA certificate, and malpractice insurance.
10. Review the completed form to ensure all information is accurate and up-to-date.

Who needs the Connecticare practitioner data form:

1. Healthcare professionals who are in-network or want to become in-network providers with Connecticare.
2. Physicians, dentists, chiropractors, psychologists, therapists, and other healthcare practitioners who wish to accept Connecticare insurance.
3. Individuals who want to update their information or make changes to their existing Connecticare practitioner data.

Note: It is always recommended to refer to the official Connecticare website or contact their customer service for the most accurate and up-to-date information regarding filling out their practitioner data form.

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What is connecticare practitioner data form?

The connecticare practitioner data form is a form used to collect and report information about healthcare practitioners who are part of the ConnectiCare network.

Who is required to file connecticare practitioner data form?

All healthcare practitioners who are part of the ConnectiCare network are required to file the connecticare practitioner data form.

How to fill out connecticare practitioner data form?

The connecticare practitioner data form can be filled out online through the ConnectiCare website or submitted through a physical form. The form requires practitioners to provide information such as their personal details, practice information, and any affiliations or certifications.

What is the purpose of connecticare practitioner data form?

The purpose of the connecticare practitioner data form is to ensure that accurate and up-to-date information is maintained for all healthcare practitioners in the ConnectiCare network. This information is used for various purposes, including provider directories, network management, and claims processing.

What information must be reported on connecticare practitioner data form?

The connecticare practitioner data form requires practitioners to report personal information (name, contact details), practice information (address, phone number), board certifications, hospital affiliations, and any specialty or subspecialty details.