Fillable SouthCarolinaPDM@centene.com Provider Data Form_ADD (Absolute Total Care)

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SouthCarolinaPDM@centene.com Provider Data Form_ADD (Absolute Total Care)

On average this form takes 33 minutes to complete

The SouthCarolinaPDM@centene.com Provider Data Form_ADD (Absolute Total Care) form is 2 pages long and contains:

  • 0 signatures
  • 26 check-boxes
  • 120 other fields

Country of origin: US
File type: PDF

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SouthCarolinaPDM@centene.com
Provider Data Form_ADD
(Or you may attach a full roster in MS Excel; please send DOO, W9, CLIA, etc.
This information will assist us in loading your providers without delay!)
Date:
Are you registered with CAQH? Yes
No
If No, please attach the SC Application.
If Yes, CAQH Provider ID:
Individual NPI:
First Name:
Middle Initial:
Date of Birth:
Social Security #:
Medicaid ID # (Note: You must have an active
SC Medicaid ID or proof of application):
Provider Type (MD, DO, NP, PA etc.):
Are you a hospital-based only provider not practicing in an office setting?
Yes No
If Yes and No – Please checkmark which location is outside the hospital:
Loc1: Loc2:
Tax ID (Attach W9):
Group Billing NPI (Attach Disclosure of Ownership):
Practice Name:
Email Address for Absolute Total Care to Contact Practice:
Primary Office Street Address:
Suite #:
Primary Office City:
State:
County:
Zip:
Primary Telephone:
Primary Fax:
Credentialing Contact Information Responsible for Roster Updates/Adds/Terms: Name, Title, Phone, Email Address , Mailing Address
Name: Title:
Direct Phone #: Email:
Mailing Address: City: ST: ZIP:
Practice Hours (Monday through Sunday)
:
M: to T: to
W: to Th: to
F: to S: to
Sun: to After Hours Clinic? (Y/N)
Afte
r Hours Hours (Monday through Sunday):
Practice Hours (Monday through Sunday):
M: to T: to
W: to Th: to
F: to S: to
Sun: to A
fter Hours Clinic? (Y/N)
After Hours Hours (Monday through Sunday):
Primary Specialty:
High Risk OB/GYN? (Y/N): Mate
rnal/Fe
tal? (Y/N):
Applying As: Specialist
Primary Care Provid
er (Nurse practitioners must adhere to
South Carolin
a Department of Health and Human Services
guidelines for practicing as a PCP before we can load as a PCP)
If PCP, are you accepting new patients?
Yes No
Yes, e
xisting patients only
What gender or age restrictions do you have?
Gender: No Restrictions Female Only Male Only
Age: No Restrictions Age Limits: Lowest Age: Highest Age:
License #:
License State:
Expiration Date:
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Are you board certified?
Yes No
If Yes, board name:
Expiration Date:
W-9 Attached? (Check Mark) Current Disclosure of Ownership Attached? (Check
Mark)
Nurse Protocol & Preceptor Documents (if NP)
Attached? (Check Mark or N/A)
________
Please list any medical related organizations you have ownership with (e.g., laboratory, home health agency, radiology facility, mobile testing, MRI,
etc.) DOO has all Info (Check Mark)
If you provide direct laboratory services, please indicate the TIN utilized and provide Clinical Laboratory Information Act (CLIA) information. Attach
a copy of your CLIA certificate or waiver if you have one.
Do you have a CLIA Certificate
Attached? Yes
No
Do you have a CLIA waiver
Attached? Yes
No
Type of Service Provided:
Certificate #:
Certificate Expiration Date:
CLIA Name:
Tax ID (TIN) #:
Secondary Office Street Address (include any additional locations on a separate page to order to load
directory information or Mark N/A):
Suite #:
Secondary Office City:
State:
County:
Zip:
Secondary Telephone:
Secondary Fax:
Practice Hours (Monday through Sunday):
M: to T: to
W: to Th: to
F: to S: to
Sun: to
After Hours Clinic? (Y/N)
A
fter Hours Hours (Monday through Sunday):
Practice
Hours (Monday through Sunday):
M: to T
: to
W: to Th: to
F: to S: to
Sun: to
After Hours Clinic? (Y/N)
A
fter Hours Hours (Monday through Sunday):
Addi
tional Locations? (Please attach roster or additional information
as above for any othe
r locations)
Any additional information for Absolute Total Care?
Your responses will allow us to load your data appropriately and assist in preventing delays in processing your request.
Thank you for participating in Absolute Total Care!
Respectfully,
The South Caro lina PDM Team
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SouthCarolinaPDM@centene.com Provider Data Form_ADD (Absolute Total Care)

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Completed 5 May 2021

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