TX AmeriHealth Caritas Provider Data Intake Form 2017 free printable template
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Com or fax it to 1-866-935-4807. Page 1 of 2 Practitioner roster from numbers listed above Waiver number if applicable from the number listed below First name Last name MI Degree Specialty CAQH registration Medicaid ID and NPI N/A NPI PCP Yes No Waiver 1 Aged blind and disabled ABD 2 home- and community-based services HCBS or 3 intermediate care facilities for individuals with intellectual disabilities ICF/IID NB-17212. Provider Data Intake Form Provider type Primary care provider PCP...
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How to fill out TX AmeriHealth Caritas Provider Data Intake Form
01
Download the TX AmeriHealth Caritas Provider Data Intake Form from the official website.
02
Fill in your personal information, including your name, address, and contact details.
03
Provide your practice information, including the type of services offered, hours of operation, and number of staff.
04
Enter your National Provider Identifier (NPI) number and tax identification number (TIN).
05
Complete the sections regarding your credentials, licenses, and certifications.
06
Provide details about your insurance contracts and affiliations with other health networks or organizations.
07
Ensure that all information is accurate and up to date.
08
Review the form for completeness and sign where required.
09
Submit the form as instructed, either electronically or by mail.
Who needs TX AmeriHealth Caritas Provider Data Intake Form?
01
Healthcare providers looking to join the AmeriHealth Caritas network.
02
Practitioners who need to update their information with AmeriHealth Caritas.
03
New service providers in the health sector requiring registration with AmeriHealth Caritas.
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What is TX AmeriHealth Caritas Provider Data Intake Form?
The TX AmeriHealth Caritas Provider Data Intake Form is a document used by healthcare providers to submit essential information for participation in the AmeriHealth Caritas network in Texas.
Who is required to file TX AmeriHealth Caritas Provider Data Intake Form?
Healthcare providers seeking to join or maintain their status in the AmeriHealth Caritas network in Texas are required to file the TX AmeriHealth Caritas Provider Data Intake Form.
How to fill out TX AmeriHealth Caritas Provider Data Intake Form?
To fill out the TX AmeriHealth Caritas Provider Data Intake Form, providers should carefully complete all sections by providing required information accurately, ensuring all fields are filled out according to the instructions provided on the form.
What is the purpose of TX AmeriHealth Caritas Provider Data Intake Form?
The purpose of the TX AmeriHealth Caritas Provider Data Intake Form is to collect necessary information from healthcare providers to facilitate their enrollment and participation in the AmeriHealth Caritas managed care network.
What information must be reported on TX AmeriHealth Caritas Provider Data Intake Form?
The information that must be reported on the TX AmeriHealth Caritas Provider Data Intake Form includes provider identification details, practice locations, specialties, and other relevant credentials and qualifications.
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