Agency Information Form - Mynexus Page 2
Download a blank fillable Agency Information Form - Mynexus in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Agency Information Form - Mynexus with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2ATTACHMENT A
If More Than Three Locations, Please Copy or Send Requested Information in a Directory Format
Branch Name:
Primary Address:
City:
State:
Zip Code:
General Contact Information:
Email:
Telephone:
Fax:
NPI #:
Federal Tax I.D. #:
State License Expiration Date:
State License #:
Medicaid # (If Certified):
CMS Certification # (If Certified):
Census – Average Daily:
Census – Full Capacity:
Primary Contact Name and Title (If Different than Previously Listed Contact):
Email Address:
Phone Number:
Branch Name:
Primary Address:
City:
State:
Zip Code:
General Contact Information:
Email:
Telephone:
Fax:
NPI #:
Federal Tax I.D. #:
State License Expiration Date:
State License #:
Medicaid # (If Certified):
CMS Certification # (If Certified):
Census – Average Daily:
Census – Full Capacity:
Primary Contact Name and Title (If Different than Previously Listed Contact):
Email Address:
Phone Number:
Branch Name:
Primary Address:
City:
State:
Zip Code:
General Contact Information:
Email:
Telephone:
Fax:
NPI #:
Federal Tax I.D. #:
State License Expiration Date:
State License #:
Medicaid # (If Certified):
CMS Certification # (If Certified):
Census – Average Daily:
Census – Full Capacity:
Primary Contact Name and Title (If Different than Previously Listed Contact):
Email Address:
Phone Number:
FOR QUESTIONS OR TO SUBMIT FORM, PLEASE RETURN TO ATTN: PROVIDER NETWORK:
VIA FAX AT 615-988-9947
VIA EMAIL AT
OR
Version 1.3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business