Caqh Provider Application – Fill Out and Use This PDF

A Caqh Provider Application is a financial service that gives you the ability to create your own checking account.

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Caqh Provider Application PDF Details

If you are a health care provider and would like to offer your services through the Caqh network, you will need to complete an application. The Caqh Provider Application is a comprehensive form that asks for detailed information about your practice. Completing the application accurately and completely is important, as it will be used to assess your candidacy for participation in the network. In order to ensure that your submission is considered, please make sure to review the application instructions carefully before submitting.

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Question	Answer
Form Name	Caqh Provider Application
Form Length	43 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	10 min 45 sec
Other names	pro caqh, proview caqh, caqh provider login, caqh proview

Form Preview Example

Provider Application

CAQH AUTOMATICALLY APPLIES MIXED-CASE FORMATTING,

CORRECT NUMBERS

CORRECT

INCORRECT

•

COMMON ABBREVIATIONS, AND ZIP CODE MATCHING. PLEASE

AND LETTERS

MARK

MARKS

MAKE CORRECTIONS ONLINE OR CALL THE HELP DESK.

Instructions

Tips to avoid processing delays

Read all instructions

Complete only this application and its supplemental forms. Do not use another provider’s application.

Use a blue or black ink ball-point pen only. Do not use a pencil or a felt-tip pen.

carefully prior to

Print legibly and inside the boxes provided based upon the examples given above.

submitting your

Do not enter more than 1 character per box. If necessary, write outside the provided spaces.

application.

Complete all sections that are applicable to you.

6. Some fields use “codes” to help you easily report information (e.g., schools, languages). Code lists are found on pages 36 - 43.

NOTE: Fields with asterisks (*) indicate that a response is required. All other fields will be considered not applicable if left blank.

SECTION 1

Personal Information and Professional IDs

Provider Type

Code list is found on page 36. Enter the

DO YOU PRACTICE EXCLUSIVELY WITHIN THE INPATIENT SETTING?*

associated 3-digit code in the space

YES

(E.G. PATHOLOGISTS, ANESTHESIOLOGISTS, ER PHYSICIANS, NURSE

provided.*

PRACTITIONER, RADIOLOGISTS, PHYSICIAN ASSISTANT, ETC.)

Name

Do not use nicknames

or initials, unless they

LAST NAME*

SUFFIX (JR, III)

are part of your legal

name.

FIRST NAME*

MIDDLE NAME

HAVE YOU EVER USED ANOTHER NAME?*

YES

IF YES, PLEASE LIST ALL OTHER NAMES USED AND THEIR DATES OF USE BELOW.

OTHER LAST NAME

SUFFIX (JR, III)

OTHER FIRST NAME

OTHER MIDDLE NAME

DATE STARTED USING OTHER NAME

DATE STOPPED USING OTHER NAME

General

Information

GENDER*

MALE

FEMALE

DATE OF BIRTH*

Only enter a Foreign

National Identification

Number if you do not

have a SSN. Do not

enter National Provider

CITY OF BIRTH

STATE OF

COUNTRY OF

Identification (NPI)

BIRTH

Number here.

SSN*

Code lists are found on

pages 36-43. Enter the

FOREIGN NATIONAL IDENTIFICATION NUMBER (FNIN)

FNIN COUNTRY OF ISSUE

associated 3-digit code

in the space provided.

ENTER ALL NON-ENGLISH

LANGUAGES YOU SPEAK

LANGUAGE CODE

Home Address

NUMBER

STREET

APT NUMBER

CITY

STATE

ZIP CODE

TELEPHONE

NOTE: CAQH will use

this method for

E-MAIL

application follow-up.

FAX

PREFERRED METHOD OF CONTACT*

E-MAIL

FAX

3076

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Page 01

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 1

Personal Information and Professional IDs (Continued)

Professional

IDs

FEDERAL DEA NUMBER

Include all state

DEA ISSUE DATE

licenses, DEA

Registration and State

Controlled Dangerous

DEA STATE OF REGISTRATION

DEA EXPIRATION DATE

Substance (CDS)

certification numbers.

Provide all current and

CDS CERTIFICATE NUMBER

CDS ISSUE DATE

previous licenses/

certifications.

CDS STATE OF REGISTRATION

CDS EXPIRATION DATE

Non-licensed

professionals should

enter certification/

registration number in

STATE LICENSE NUMBER

LICENSE ISSUING STATE

LICENSE ISSUE DATE

the space provided for

IF THIS IS A STATE LICENSE, ARE YOU

license number.

YES

CURRENTLY PRACTICING IN THIS STATE?

If you have additional

LICENSE EXPIRATION DATE

Professional IDs to

report, use the

Code list is found on page 36;

Professional IDs

use license status codes. Enter

use provider type codes. Enter

Supplemental Form on

3-digit code in space provided.

LICENSE STATUS CODE

page 19.

LICENSE TYPE

STATE LICENSE NUMBER

LICENSE ISSUING STATE

LICENSE ISSUE DATE

IF THIS IS A STATE LICENSE, ARE YOU

YES

CURRENTLY PRACTICING IN THIS STATE?

LICENSE EXPIRATION DATE

Code list is found on page 36;

use license status codes. Enter

use provider type codes. Enter

3-digit code in space provided.

LICENSE STATUS CODE

LICENSE TYPE

Other ID

ARE YOU A PART-

YES

Numbers

ICIPATING MEDICARE

PROVIDER?*

MEDICARE NUMBER

UPIN

If you have additional

ARE YOU A PART-

Professional IDs to

ICIPATING MEDICAID

YES

report, use the

PROVIDER?*

MEDICAID NUMBER

MEDICAID STATE

Professional IDs

Supplemental Form on

page 19.

NATIONAL PROVIDER IDENTIFICATION (NPI) NUMBER

USMLE NUMBER (WITHOUT HYPHENS)

WORKERS COMPENSATION NUMBER

—

ECFMG NUMBER (NON-U.S./CANADIAN GRADUATE ONLY)

ECFMG CERTIFICATE ISSUE DATE (NON-U.S./CANADIAN GRADUATE ONLY)

3077

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Page 02

Section 2

Education and Training

Undergraduate

UNDERGRADUATE SCHOOL

School(s)

Provide the appropriate

information for the

OFFICIAL NAME OF UNDERGRADUATE SCHOOL

school that issued your

undergraduate degree

and all schools

attended.

ADDRESS

CITY

STATE

ZIP/POSTAL CODE

Professional

School(s)

Provide the appropriate

COUNTRY CODE

TELEPHONE

FAX

information for the

school that issued your

professional degree.

START DATE

END DATE (GRADUATION DATE)

DEGREE AWARDED

Fifth Pathway Graduates

DID YOU COMPLETE YOUR

YES

please complete the

UNDERGRADUATE EDUCATION

following sections: U.S.

AT THIS SCHOOL?

School that issued your

certificate, the Non-U.S.

GRADUATE TYPE*:

School where you

attended, and the Fifth

Pathway institution

U.S. OR CANADIAN GRADUATE

NON-U.S./CANADIAN GRADUATE

FIFTH PATHWAY GRADUATE

where you completed

your training on

U.S. OR CANADIAN SCHOOL

Supplemental Page 20.

Code lists are found on

SCHOOL CODE (U.S./

NAME OF U.S./

pages 36-43. Enter the

CANADIAN ONLY)

CANADIAN SCHOOL:

associated 3-digit code

in the space provided.

If you have additional

START DATE*

END DATE (GRADUATION DATE)*

DEGREE AWARDED

Undergraduate or

Professional Schools to

DID YOU COMPLETE YOUR

report, use the

GRADUATE EDUCATION AT THIS

YES

Education Supplemental

SCHOOL?

Form on page 20.

NON - U.S. OR CANADIAN SCHOOL

OFFICIAL NAME OF NON-U.S. PROFESSIONAL SCHOOL

ADDRESS

CITY

COUNTRY CODE

POSTAL CODE

START DATE*

END DATE (GRADUATION DATE)*

DEGREE AWARDED

DID YOU COMPLETE YOUR

YES

GRADUATE EDUCATION AT THIS

SCHOOL?

3078

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Page 03

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 2

Education and Training (Continued)

Training

List all training

SCHOOL CODE (E.G.,

programs you

AFFILIATED MEDICAL

attended. Use one

SCHOOL)

section per institution.

INSTITUTION/HOSPITAL NAME (USE BOTH LINES IF REQUIRED)

If you have additional

post-graduate training

programs, use the

NUMBER

STREET

SUITE/BUILDING

Supplemental Training

Form on page 21.

Please explain on the

CITY

STATE

ZIP/POSTAL CODE

Supplemental

Professional / Work

History Gap Form on

page 33 any training

COUNTRY CODE

TELEPHONE

FAX

gap(s) of three (3)

months or greater, or

DID YOU COMPLETE THIS TRAINING PROGRAM AT THIS

YES

any gap(s) of a shorter

INSTITUTION?

duration if required by

(IF NOT, PLEASE USE THE SPACE BELOW TO EXPLAIN.)

the organization for

which you are being

credentialed.

Code lists are found on pages 36-43. Enter the associated 3-digit code in the space provided.

List each

INTERNSHIP/

FELLOWSHIP

OTHER

RESIDENCY

department

separately, if

START DATE

END DATE

applicable.

List

DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)

Internship/

Residency,

Fellowship

and Other

NAME OF DIRECTOR

programs

separately.

INTERNSHIP/

FELLOWSHIP

OTHER

RESIDENCY

START DATE

END DATE

DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)

NAME OF DIRECTOR

INTERNSHIP/

RESIDENCY

FELLOWSHIP OTHER M M Y Y Y Y M M Y Y Y Y

START DATE

END DATE

DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)

NAME OF DIRECTOR

3080

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Page 04

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 3

Professional / Medical Specialty Information

Primary

SPECIALTY

INITIAL

DO YOU WISH TO

HMO

YES

Specialty

CODE

CERTIFICATION

BE LISTED IN

DATE

THE DIRECTORY

RECERTIFICATION

UNDER THIS

Code lists are found on

BOARD

YES

SPECIALTY?

PPO

YES

DATE

CERTIFIED?

pages 36-43. Enter the

(IF APPLICABLE)

associated 3-digit code

CERTIFYING

EXPIRATION DATE

in the space provided.

POS

YES

BOARD

(IF APPLICABLE)

CODE

IF NOT

I HAVE TAKEN

I INTEND TO SIT FOR AN

I DO NOT INTEND TO TAKE

BOARD

EXAM, RESULTS

EXAM ON

A CERTIFYING BOARD EXAM.

CERTIFIED

PENDING FOR

(SELECT

ONE)

CERTIFYING BOARD CODE

IF YOU INDICATED THAT YOU DID NOT INTEND TO TAKE A CERTIFYING BOARD EXAM, PLEASE USE THE

FOLLOWING SPACE TO EXPLAIN, OTHERWISE LEAVE THE SPACE BLANK.

Secondary

SPECIALTY

INITIAL

DO YOU WISH TO

HMO

YES

Specialty

CODE

CERTIFICATION

BE LISTED IN

DATE

THE DIRECTORY

RECERTIFICATION

UNDER THIS

Code lists are found on

BOARD

YES

SPECIALTY?

PPO

YES

DATE

CERTIFIED?

pages 36-43. Enter the

(IF APPLICABLE)

associated 3-digit code

CERTIFYING

EXPIRATION DATE

in the space provided.

POS

YES

BOARD

(IF APPLICABLE)

CODE

If you have additional

IF NOT

I HAVE TAKEN

I INTEND TO SIT FOR AN

Professional / Medical

I DO NOT INTEND TO TAKE

BOARD

EXAM, RESULTS

Specialties to report,

EXAM ON

A CERTIFYING BOARD EXAM.

CERTIFIED

PENDING FOR

use the Additional

(SELECT

Specialties

ONE)

Supplemental Form on

page 22.

CERTIFYING BOARD CODE

IF YOU INDICATED THAT YOU DID NOT INTEND TO TAKE A CERTIFYING BOARD EXAM, PLEASE USE THE

FOLLOWING SPACE TO EXPLAIN, OTHERWISE LEAVE THE SPACE BLANK.

3081

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Page 05

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 3

Professional / Medical Specialty Information (Continued)

Certifications

Do you hold the following certifications? If yes, provide expiration dates.

EXPIRATION DATE

BASIC LIFE

ADV LIFE

YES

SUPPORT IN

YES

SUPPORT?*

OB?*

ADV TRAUMA

CPR?*

YES

LIFE

YES

SUPPORT?*

ADV

PEDIATRIC

CARDIAC

YES

ADVANCED

YES

LIFE SPT?*

NEONATAL

ADVANCED

YES

LIFE SPT?*

Practice

Interests

Provide additional

areas of professional

practice interest,

activities, procedures,

diagnoses or

populations.

Primary

Credentialing

Contact

LAST NAME

CHECK HERE TO

USE THE OFFICE

FIRST NAME

M.I.

MANAGER AND

ADDRESS OF THE

PRIMARY PRACTICE

LOCATION AS THE

NUMBER

STREET

SUITE/BUILDING

CREDENTIALING

INFORMATION.

CITY

STATE

ZIP CODE

NOTE:

Even if you checked

TELEPHONE

FAX

the boxes above,

please provide the

e-mail address, if

E-MAIL ADDRESS

available.

3082

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Page 06

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 4

Practice Location Information

Primary

NOTE: IF YOU INDICATED THAT YOU PRACTICE EXCLUSIVELY WITHIN THE INPATIENT SETTING ON PAGE 1, YOU ARE ONLY REQUIRED TO COMPLETE THE

Practice

CREDENTIALING CONTACT QUESTION ABOVE. SECTION 4 MAY BE LEFT BLANK. YOU MAY PROCEED TO SECTION 5 ON PAGE 11.

Location

CURRENTLY

YES

IF NO, WHAT IS

PRACTICING AT

YOUR EXPECTED

THIS ADDRESS?*

START DATE?

If you have additional

practice locations, use

the Supplemental

PHYSICIAN GROUP / PRACTICE NAME TO APPEAR IN DIRECTORY (DO NOT ABBREVIATE)*

Practice Location

Information Form on

pages 25-29.

GROUP / CORPORATE NAME AS IT APPEARS ON W-9, IF DIFFERENT FROM ABOVE (DO NOT ABBREVIATE)

NOTE: “General

Correspondence” refers

to any correspondence

NUMBER*

STREET*

SUITE/BUILDING

that might be sent to the

provider that does not

solely relate to creden-

CITY*

STATE*

ZIP CODE*

tialing or billing

information.

SEND GENERAL

YES

CORRESPON-

TIP Your Individual Tax

DENCE HERE?*

TELEPHONE*

FAX

ID is assumed to be

your Primary Tax ID

unless you specify

otherwise to the right.

OFFICE E-MAIL ADDRESS

PRIMARY

USE INDIVIDUAL

USE GROUP

TAX ID

(ONE ONLY)*

INDIVIDUAL TAX ID

GROUP TAX ID

Office Manager

or Business

Office Staff

LAST NAME*

Contact

List each contact

FIRST NAME*

M.I.

separately. You may

use the check boxes

below for convenience.

TELEPHONE*

FAX

Do not write

instructions like “see

above”. These

responses will be

E-MAIL ADDRESS

rejected and will

require follow-up.

Billing Contact

LAST NAME*

CHECK HERE TO

USE OFFICE

MANAGER AND

OFFICE ADDRESS

FIRST NAME*

M.I.

AS BILLING

INFORMATION

NUMBER*

STREET*

SUITE/BUILDING

NOTE:

Even if you checked

CITY*

STATE*

ZIP CODE*

the box above, please

provide the

E-mail Address of the

TELEPHONE*

FAX

Billing Contact.

E-MAIL ADDRESS

3083

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Page 07

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 4

Practice Location Information (Continued)

Payment and

ELECTRONIC

YES

Remittance

BILLING

CAPABILITIES?*

BILLING DEPARTMENT (IF HOSPITAL-BASED)

YOUR “CHECK PAYABLE TO”

INFORMATION SHOULD BE

CONSISTENT WITH YOUR

W-9.

CHECK PAYABLE TO*

CHECK HERE TO

USE OFFICE

MANAGER AND

OFFICE ADDRESS

LAST NAME*

AS PAYEE

INFORMATION

FIRST NAME*

M.I.

NUMBER*

STREET*

SUITE/BUILDING

NOTE:

Even if you checked

CITY*

STATE*

ZIP CODE*

the box above, please

provide the

E-mail Address of the

TELEPHONE*

FAX

Payee Contact.

E-MAIL ADDRESS

Office Hours

(USE HHMM FORMAT AND ROUND TO THE NEAREST HALF-HOUR)

START

A=AM

END

A=AM

START

A=AM

END

A=AM

P=PM

MONDAY

FRIDAY

TUESDAY

SATURDAY

WEDNESDAY

SUNDAY

NOTE:

THURSDAY

After hours back office

telephone will be used

only by the health plan

24/7 PHONE COVERAGE?*

IF YES

AFTER HOURS BACK OFFICE TELEPHONE

and will not be

ANSWERING

VOICE MAIL WITH

VOICE MAIL

published under any

YES

INSTRUCTIONS TO CALL

WITH OTHER

SERVICE

circumstances.

ANSWERING SERVICE

INSTRUCTIONS

Open Practice

ACCEPT NEW PATIENTS INTO THIS PRACTICE?*

YES

ACCEPT ALL NEW PATIENTS?*

YES

Status

ACCEPT EXISTING PATIENTS WITH CHANGE OF PAYOR?*

YES

ACCEPT NEW MEDICARE PATIENTS?*

YES

ACCEPT NEW PATIENTS WITH PHYSICIAN REFERRAL?*

YES

ACCEPT NEW MEDICAID PATIENTS?*

YES

IF ANY OF THE

ABOVE INFORMATION

VARIES BY PLAN,

EXPLAIN (USE BOTH

LINES IF REQUIRED)

ARE THERE ANY

GENDER LIMITATIONS

AGE LIMITATIONS

LIST OTHER LIMITATIONS

PRACTICE LIMITATIONS?*

MALE

MINIMUM

ONLY

NONE

AGE

YES

IF YES

FEMALE

MAXIMUM

ONLY

AGE

3084

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Page 08

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 4

Practice Location Information (Continued)

Mid-Level

DO MID-LEVEL PRACTITIONERS (NURSE PRACTITIONERS, PHYSICIAN

YES

ASSISTANTS, ETC.) CARE FOR PATIENTS IN YOUR PRACTICE?*

Practitioners

(IF YES, PLEASE PROVIDE THE INFORMATION BELOW)

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE (E.G., PA,

CNP, NP)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE (E.G., PA,

CNP, NP)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE (E.G., PA,

CNP, NP)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE (E.G., PA,

CNP, NP)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE (E.G., PA,

CNP, NP)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

3085

* REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Page 09

*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 4

Practice Location Information (Continued)

Languages

LANGUAGES

NON-ENGLISH LANGUAGES

Code lists are found on

SPOKEN BY OFFICE PERSONNEL

pages 37. Enter the

LANGUAGE CODE

associated 3-digit code

in the space provided.

INTERPRETERS

YES

LANGUAGES

AVAILABLE?*

INTERPRETED

LANGUAGE CODE

Accessibilities

DOES THIS OFFICE MEET ADA ACCESSIBILITY REQUIREMENTS?*

YES

DOES THIS SITE OFFER HANDICAPPED

DOES THIS SITE OFFER OTHER

YES

ACCESSIBLE BY

YES

ACCESS FOR THE FOLLOWING

SERVICES FOR THE DISABLED?*

PUBLIC TRANSPORTATION?*

YES

BUS*

YES

BUILDING?*

TEXT TELEPHONY (TTY)*

YES

PARKING?*

YES

AMERICAN SIGN LANGUAGE*

YES

SUBWAY*

MENTAL/PHYSICAL IMPAIRMENT

REGIONAL TRAIN*

YES

RESTROOM?*

YES

SERVICES*

OTHER HANDICAPPED ACCESS

OTHER DISABILITY SERVICES

OTHER TRANSPORTATION ACCESS

Services

Does this location provide any of the following services?

LABORATORY

IF YES, PROVIDE ACCREDITING/

YES

CERTIFYING PROGRAM

SERVICES?

(E.G., CLIA, COLA, MLE)

RADIOLOGY

YES

IF YES, PROVIDE X-RAY

SERVICES?

CERTIFICATION TYPE

EKGS?

YES

ALLERGY

YES

ALLERGY SKIN

YES

ROUTINE OFFICE

YES

GYNECOLOGY

INJECTIONS?

TESTING?

(PELVIC/PAP)?

AGE

DRAWING

YES

FLEXIBLE

YES

TYMPANOMETR

YES

BLOOD?

APPROPRIATE

Y/ AUDIOMETRY

IMMUNIZATIONS?

SIGMOIDOSCOPY?

SCREENING?

ASTHMA

YES

OSTEOPATHIC

YES

IV HYDRATION/

YES

CARDIAC

YES

TREATMENT?

MANIPULATION?

TREATMENT?

STRESS TEST?

PULMONARY

YES

PHYSICAL

YES

CARE OF MINOR

YES

FUNCTION

THERAPY?

LACERATIONS?

TESTING?

IF YES, WHAT

IS ANESTHESIA

ADMINISTERED IN

YES

CLASS/CATEGORY

YOUR OFFICE?

DO YOU USE?

IF YES, WHO

ADMINISTERS IT?

LAST NAME

FIRST NAME

TYPE OF PRACTICE

SOLO PRACTICE

SINGLE SPECIALTY GROUP

MULTI-SPECIALTY GROUP

(SELECT ONE ONLY)*

ADDITIONAL OFFICE PROCEDURES PROVIDED (INCLUDING SURGICAL PROCEDURES)

3086

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Page 10

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Step 1: The first step requires you to hit the orange "Get Form Now" button.

Step 2: Now you're on the file editing page. You may enhance and add information to the file, highlight words and phrases, cross or check certain words, insert images, put a signature on it, delete needless fields, or remove them entirely.

If you want to prepare the proview caqh PDF, enter the information for each of the sections:

stage 1 to completing caqh provider login

Complete the M M D D Y Y Y Y, M M D D Y Y Y Y, DATE STARTED USING OTHER NAME, DATE STOPPED USING OTHER NAME, GENDER MALE FEMALE, DATE OF BIRTH, M M D D Y Y Y Y, CITY OF BIRTH, SSN, ENTER ALL NONENGLISH LANGUAGES YOU, STATE OF BIRTH, COUNTRY OF BIRTH, FOREIGN NATIONAL IDENTIFICATION, FNIN COUNTRY OF ISSUE, and LANGUAGE CODE area with the data demanded by the application.

step 2 to entering details in caqh provider login

The system will demand you to give some vital info to automatically submit the segment EMAIL, FAX, NOTE CAQH will use this method for, PREFERRED METHOD OF CONTACT, EMAIL, FAX, REQUIRED RESPONSE NO RESPONSE MAY, and Page.

part 3 to filling out caqh provider login

Spell out the rights and obligations of the parties in the section Section, Personal Information and, Professional IDs, Include all state licenses DEA, Provide all current and previous, Nonlicensed professionals should, If you have additional, FEDERAL DEA NUMBER, M M D D Y Y Y Y, DEA ISSUE DATE, M M D D Y Y Y Y, DEA STATE OF REGISTRATION, DEA EXPIRATION DATE, CDS CERTIFICATE NUMBER, and CDS ISSUE DATE.

End by taking a look at the following areas and filling them out accordingly: LICENSE EXPIRATION DATE, Code list is found on page use, Code list is found on page use, LICENSE STATUS CODE, LICENSE TYPE, ARE YOU A PART ICIPATING MEDICARE, ARE YOU A PART ICIPATING MEDICAID, YES NO, YES NO, Other ID Numbers, If you have additional, MEDICARE NUMBER, UPIN, MEDICAID NUMBER, and MEDICAID STATE.

Step 3: Choose the Done button to save the form. At this point it is accessible for export to your device.

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