Edit, Download, and Sign the 1199SEIU Benefit Funds Provider Recruitment Form
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How do I fill this out?
To fill out the 1199SEIU Benefit Funds Provider Recruitment Form, complete all required fields with accurate information. Ensure your CAQH attestation is up to date. Submit the form via fax or email for processing.
How to fill out the 1199SEIU Benefit Funds Provider Recruitment Form?
1
Complete all required fields marked with an asterisk.
2
Provide accurate information for provider and credentialing contact details.
3
Ensure CAQH attestation and malpractice insurance are current.
4
Sign and date the form.
5
Submit the form via fax or email for processing.
Who needs the 1199SEIU Benefit Funds Provider Recruitment Form?
1
Healthcare providers looking to join the 1199SEIU Benefit Funds network.
2
Providers who wish to offer services to 1199SEIU members.
3
Providers who need to update their credentialing information with 1199SEIU.
4
Practice groups interested in expanding their network affiliation.
5
Providers seeking compliance with the Council for Affordable Quality Healthcare requirements.
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2
Fill in the required fields with accurate information.
3
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4
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5
Download or share the updated form.
What are the instructions for submitting this form?
To submit the 1199SEIU Benefit Funds Provider Recruitment Form, complete all required fields, sign, and date the form. Submit via fax to (646) 473-7213 or email to Providers@1199Funds.org. Allow up to 45 days from receipt for processing.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates mentioned for this form in 2024 and 2025.
What is the purpose of this form?
The purpose of the 1199SEIU Benefit Funds Provider Recruitment Form is to allow healthcare providers to request participation in the Benefit Funds' network. By completing this form, providers indicate their interest in servicing members of the 1199SEIU Benefit Funds. This form is an essential step in ensuring that providers meet the necessary credentialing and network adequacy guidelines to become part of the network.
Tell me about this form and its components and fields line-by-line.
- 1. PROVIDER'S LEGAL NAME: The legal name of the provider.
- 2. ETHNICITY: The ethnicity of the provider, with a selection option.
- 3. GROUP/PRACTICE NAME: The name of the provider's group or practice.
- 4. PRIMARY SERVICE LOCATION: The primary location where services are provided.
- 5. OFFICE PHONE: The contact phone number for the office.
- 6. OFFICE CONTACT: The primary contact person at the office.
- 7. PROVIDER'S EMAIL ADDRESS: The provider's official email address for notices.
- 8. CREDENTIALING CONTACT NAME: The name of the person responsible for credentialing.
- 9. DATE: The current date in MM/DD/YYYY format.
- 10. DATE OF BIRTH: The provider's date of birth for secondary validation.
- 11. PROVIDER'S SECONDARY LANGUAGE(S): Any secondary languages spoken by the provider, with a selection option.
- 12. TAX ID #: The provider's tax identification number.
- 13. CITY: The city where the provider's office is located.
- 14. STATE: The state where the provider's office is located.
- 15. OFFICE FAX: The fax number for the office.
- 16. WEBSITE ADDRESS: The website address, if applicable.
- 17. PATIENT-FACING EMAIL: The email address used for patient communication, if different.
- 18. CREDENTIALING CONTACT PHONE NUMBER: The phone number for the credentialing contact.
- 19. GENDER: The gender of the provider.
- 20. ZIP CODE: The ZIP code for the provider's office location.
- 21. CREDENTIALING CONTACT EMAIL ADDRESS: The email address for the credentialing contact.
- 22. BEST METHOD OF CONTACT FOR QUESTIONS AND TO RECEIVE COMMUNICATIONS FROM THE BENEFIT FUNDS: The preferred method of contact for questions and communications.
- 23. PRIMARY SPECIALTY: The primary specialty the provider is applying as.
- 24. BOARD CERTIFIED: Indicates whether the provider is board certified.
- 25. SECONDARY SPECIALTY: The secondary specialty the provider is applying as, if applicable.
- 26. INDIVIDUAL NATIONAL PROVIDER IDENTIFIER (NPI): The provider's NPI number, which must be 10 digits.
- 27. CAQH ID #: The provider's CAQH identification number.
- 28. HOSPITAL AFFILIATION: The primary admitting hospital, if applicable.
What happens if I fail to submit this form?
Failure to submit the form may result in delays or denial of participation in the 1199SEIU Benefit Funds network. It is crucial to complete and submit the form accurately and timely.
- Delays in Processing: Incomplete forms may cause delays in the evaluation process.
- Denial of Participation: Failure to provide accurate or complete information may lead to denial of participation.
How do I know when to use this form?
- 1. Joining the Network: New providers seeking to join the 1199SEIU Benefit Funds network.
- 2. Updating Credentialing Information: Existing providers needing to update their information with 1199SEIU.
- 3. Expanding Practice Group Affiliation: Practice groups interested in expanding their network affiliation.
Frequently Asked Questions
How do I fill out the 1199SEIU Benefit Funds Provider Recruitment Form?
Complete all required fields, ensure CAQH attestation is current, sign, and submit via fax or email.
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Yes, PrintFriendly allows you to share the filled and signed form using its sharing options.
What if my CAQH attestation is outdated?
Ensure your CAQH attestation is updated before submitting the form to avoid delays.
How long does it take to process the form?
Allow up to 45 days from receipt for processing the form.
Can I submit the form online?
Yes, you can submit the form via fax or email, as provided in the instructions.
What if I miss a required field?
Ensure all required fields marked with an asterisk are completed to avoid submission delays.
How do I know if my request for participation is approved?
You will receive written notification once your request for participation has been evaluated.
What information do I need from my doctor?
Provide your doctor's details in the member information section, and your doctor will complete the remaining provider information.
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