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EXHIBIT B PARTICIPATING PROVIDER PROFILE ADDENDUM (All information is required for CAPS enrollment) ? Updated/Renewal ? New Pharmacy DBA Name: Corporate Name: Street Address City State Zip Mailing

How to fill out participating provider profile addendum

How to fill out participating provider profile addendum:

1. Gather all necessary information: Before filling out the addendum, ensure that you have all the required information at hand. This may include your personal details, contact information, professional credentials, and any relevant insurance information.
2. Review the addendum form: Carefully read through the participating provider profile addendum form to understand the specific sections and information required from you. This will help you provide accurate and complete information.
3. Complete the personal information section: Start by filling out the personal information section, which may include your full name, address, phone number, email address, and any other requested details. Make sure to provide accurate and up-to-date information.
4. Provide professional credentials: If applicable, include your professional credentials, such as your medical or dental license number, certifications, or any other licenses required for your practice. This helps validate your qualifications as a participating provider.
5. Include insurance details: If you are participating in an insurance network, provide the necessary insurance details, such as the insurance plan name, provider ID, and any other relevant information requested. This helps establish your affiliation with the insurance network.
6. Sign and date the addendum: Once you have filled out all the required sections, sign and date the addendum form. By doing so, you confirm the accuracy of the information provided and your agreement to the terms and conditions.
7. Submit the addendum: After completing the addendum, submit it as instructed by the relevant organization or insurance network. This may involve mailing the form, submitting it electronically, or following any specific submission guidelines provided.

Who needs participating provider profile addendum?

The participating provider profile addendum typically needs to be filled out by healthcare professionals or service providers who wish to join or update their information with insurance networks or organizations. It is commonly required for healthcare providers such as doctors, dentists, specialists, and other medical professionals who want to participate in insurance plans and be recognized as network providers. By completing the addendum, providers can establish their eligibility, credentials, and affiliation with the insurance network.

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