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Get the free Form 996 - Provider-Sponsored Integrated Health Delivery Network Application

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Commonwealth of Kentucky Department of Insurance P.O. Box 517 215 West Main Street Frankfort, KY 40602 5025646082 FAX 5025644604APPLICATION FOR CERTIFICATE OF FILING AS A PROVIDERSPONSORED INTEGRATED
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How to fill out form 996 - provider-sponsored

01
Step 1: Start by reading the instructions provided with the form.
02
Step 2: Fill out your personal information in the designated fields, such as name, address, and contact information.
03
Step 3: Provide the necessary details about the healthcare provider who is sponsoring the form, such as their name, address, and tax identification number.
04
Step 4: Indicate the type of service or treatment being provided by the healthcare provider.
05
Step 5: If applicable, provide details about any insurance coverage you have for the services mentioned in the form.
06
Step 6: Review the completed form to ensure all the information provided is accurate and complete.
07
Step 7: Sign and date the form.
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Step 8: Make copies of the form for your records, and submit the original form to the appropriate healthcare authority or organization.

Who needs form 996 - provider-sponsored?

01
Form 996 - provider-sponsored is required by individuals who have received healthcare services from a specific provider and need to report those services for reimbursement or record-keeping purposes.
02
This form is typically used by patients or individuals seeking reimbursement from insurance companies, government agencies, or employers who have a provider-sponsored healthcare plan.
03
It helps ensure that the services provided by the healthcare provider are accurately documented and accounted for.
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Form 996 - provider-sponsored is a form used by certain healthcare providers to report their sponsorship of Medicare Advantage plans.
Healthcare providers that intend to offer or are currently offering Medicare Advantage plans must file Form 996.
To fill out Form 996, providers must provide their identifying information, details about the sponsored plan, and any relevant financial information as required by the form instructions.
The purpose of Form 996 is to ensure that provider-sponsored organizations comply with Medicare regulations and accurately report their financial and operational data.
Form 996 requires providers to report information such as organizational structure, ownership, finances, and details relating to the Medicare Advantage plan they sponsor.
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