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

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

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

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  • 12 check-boxes
  • 100 other fields

Country of origin: US
File type: PDF

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SouthCarolinaPDM@centene.com
Provider Data Form_UPDATE
(Or you may attach a full roster in MS Excel; please send Current DOO, W9, CLIA, etc.
This information will assist us in updating your demographics without delay!)
Date:
Are you registered with CAQH? Yes No
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 Current 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:
Name: Title:
Direct Phone #: Email:
Mailing Addre
ss: 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 After Hours Clinic? (Y/N)
Afte
r Hours Hours (Monday through Sunday):
W-9 Attached? (Check Mark)
Disclosure of Ownership Attached? (Check Mark)
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:
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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 Sund
ay):
Practice Hours (Monday through Sunday):
M: to T: to
W: to Th: to
F: to S: to
Sun: to Afte
r Hours Clinic? (Y/N)
After Hours Hours (Monday through Sund
ay):
Your responses will allow us to review your current data and assist us in updating our systems.
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_UPDATE (Absolute Total Care)

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Completed 5 May 2021

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