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This document serves as an addendum for applicants to the Medicaid Preferred Physicians and Children Program, detailing requirements for enrollment as a medical or dental specialist.
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How to fill out Addendum to Application for Enrollment as a Medical or Dental Specialist
01
Read the instructions carefully before starting the form.
02
Gather all necessary documents, including your license and training certificates.
03
Fill in your personal information, ensuring everything matches your identification documents.
04
Provide details about your current practice or position.
05
List your educational background and any relevant qualifications.
06
Complete the sections related to your medical or dental specialty.
07
Review your answers for accuracy and completeness.
08
Sign and date the addendum.
09
Submit the completed addendum along with your application.
Who needs Addendum to Application for Enrollment as a Medical or Dental Specialist?
01
Individuals applying for enrollment as medical or dental specialists.
02
Healthcare professionals seeking to participate in specific health insurance programs.
03
Practitioners looking to update their credentials with their respective governing bodies.
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CMS Forms. The Centers for Medicare & Medicaid Services (CMS) is a Federal agency within the U.S. Department of Health and Human Services. Many CMS program related forms are available in Portable Document Format (pdf).
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How do I submit a claim? If your provider or pharmacy is in your plan's network, they'll submit the claim for you. If you saw an out-of-network provider, you'll need to submit a medical claim form. If this was for emergency care, call us first at 800-352-2583 to see if a claim was filed.
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Fax the request and all necessary documents to us at 1-877-219-9448. Please be sure to provide all necessary medical records and documentation required for us to determine an exemption.
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What is Addendum to Application for Enrollment as a Medical or Dental Specialist?
The Addendum to Application for Enrollment as a Medical or Dental Specialist is a supplementary document required for healthcare professionals who wish to enroll as specialists in the medical or dental fields. It provides additional information necessary for the enrollment process.
Who is required to file Addendum to Application for Enrollment as a Medical or Dental Specialist?
Healthcare professionals seeking to be recognized as medical or dental specialists, including those applying for new specialties or updating their existing information, are required to file this addendum.
How to fill out Addendum to Application for Enrollment as a Medical or Dental Specialist?
To fill out the Addendum, applicants must complete all required fields accurately, providing specific details about their qualifications, specialty training, and any supporting documentation or proof of specialty.
What is the purpose of Addendum to Application for Enrollment as a Medical or Dental Specialist?
The purpose of the Addendum is to collect detailed and supplemental information that verifies an applicant’s credentials, qualifications, and specialty status, ensuring compliance with enrollment requirements.
What information must be reported on Addendum to Application for Enrollment as a Medical or Dental Specialist?
Applicants must report information including their specific areas of specialty, educational background, training details, board certifications, and any relevant clinical experience or practice history.
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