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INSTRUCTIONS FOR STATE PUBLICATION 286, PROVIDER AGREEMENT INDIANA STATE DEPARTMENT OF HEALTH ALL BILLING PROVIDERS ARE REQUIRED TO: Sign the Provider Agreement Read Schedule A Complete Schedule B Provide

How to fill out provider enrollment agreement

How to fill out provider enrollment agreement

1. Obtain a provider enrollment agreement form from the appropriate healthcare payer or insurance company.
2. Read the instructions and requirements carefully to ensure that all necessary information and documentation is provided.
3. Provide your personal and professional information, including name, contact details, and any relevant licenses or certifications.
4. Fill out the agreement form accurately, making sure to answer all the required questions.
5. Include any additional supporting documentation that may be required, such as proof of liability insurance or a W-9 form.
6. Review the completed agreement form for any errors or missing information.
7. Sign and date the agreement form, certifying that all the information provided is true and accurate.
8. Make copies of the completed agreement form and any supporting documentation for your records.
9. Submit the signed and completed agreement form along with any required documentation to the healthcare payer or insurance company, either electronically or by mail.
10. Follow up with the payer or insurance company to ensure that your enrollment is processed and approved.

Who needs provider enrollment agreement?

1. Healthcare providers, such as doctors, dentists, hospitals, clinics, and other healthcare facilities, who wish to participate in a specific healthcare payer's network or accept insurance plans, typically need to fill out a provider enrollment agreement.

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