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Step 1: Select the "Get Form Now" button to get started on.
Step 2: At the time you access the health delivery organization editing page, you will see all the functions it is possible to undertake with regards to your document at the upper menu.
Provide the necessary data in each one part to create the PDF health delivery organization
You should prepare the ORGANIZATION INFORMATION, Provide physical location, Legal Name of Organization Legal, Organization Medicare primary, Organization Medicaid primary, Organization TIN primary, Credentialing Contact, Street Address, Address Line City, Contact Name, Email, Phone, Organization NPI primary, Billing Address if different than, and Street Address box with the required data.
It is vital to note some details in the section Please attach a copy of your, Please check here if your facility, Professional Liability Insurance, Current Carrier Name, Policy Start Date, Policy End Date, Coverage amount per occurrence, Policy Number Policy Type, Coverage amount aggregate, General Liability Insurance, Current Carrier Name, Policy Start Date, Policy End Date, Coverage amount per occurrence, and Policy Number Policy Type.
The PHYSICAL LOCATION INFORMATION, Include any additional information, Location DBA if different than the, Is this location Medicare Certified, Yes, Is this the primary address, Yes, Sitespecific Medicaid, Sitespecific NPI, State provider if applicable LTC, Is this location handicap, Yes, Sitespecific Medicare, Sitespecific TIN, and Physical Practice Location Street box may be used to indicate the rights and responsibilities of each party.
Fill out the template by looking at the next areas: Location State Licenses andor, Please check here if this location, Type of Credential State License, Other, State, Number, Expiration Date, Most Recent Survey Date, Additional Location Credentials, Please check here if this location, Type of Credential DEA CLIA State, Other, State, Number, and Expiration Date.
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