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This document serves as an application for credentialing Behavioral Health practitioners with various health plans, including Harvard Pilgrim Health Care and Tufts Health Plan. It collects essential information regarding the practitioner\'s identity, qualifications, practice details, and specialties, ensuring compliance with credentialing requirements.
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How to fill out ancillary practitioner data form

01
Gather personal information such as name, address, and contact details.
02
Collect professional credentials, including education and training history.
03
Document current employment information including the name of the practice or institution.
04
Include details of specialties or areas of expertise.
05
Provide any relevant certifications or licenses.
06
Ensure all information is accurate and up to date.
07
Review the completed form for any missing information before submission.
08
Submit the form to the relevant authority or organization as instructed.

Who needs ancillary practitioner data form?

01
Ancillary practitioners seeking to practice in a specific healthcare setting.
02
Healthcare institutions requiring documentation of ancillary practitioner qualifications.
03
Licensing boards or regulatory bodies reviewing practitioner credentials.
04
Insurance companies needing to verify practitioner information for policy issuance.
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The ancillary practitioner data form is a document used to collect and report information about licensed ancillary healthcare practitioners.
Healthcare institutions and organizations that employ ancillary practitioners are required to file the ancillary practitioner data form.
To fill out the ancillary practitioner data form, you must provide accurate and complete information regarding the individual practitioners, including their qualifications, roles, and practice locations.
The purpose of the ancillary practitioner data form is to ensure proper tracking, regulation, and oversight of ancillary healthcare practitioners for compliance and quality assurance.
The form must report information such as the practitioner's full name, professional title, license number, practice location, and employment status.
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credentialing behavioral health health plans Harvard Pilgrim Tufts Health Plan CAQH mental health provider application telehealth services medical practice

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