Instructions for Completing the Provider OnBoarding Application

• Complete all sections of the application.
• Determine that the information contained in the application is up-to-date and correct.
• Edit any incorrect information and insert additions where necessary.
• Attach/upload copies of documents as requested throughout the application and as determined by the checklist.
• Submit the completed application by selecting the SUBMIT AND PRINT button at the end of the application.
• Print and keep the application form for your files and future use.

By following the instructions above, your signature will be electronic and the date will be current. The information on the application must be complete and accurate. An incomplete application will delay processing.

If you have any questions completing this application, please call OnBoarding Specialist at (555) 555-5555.