Provider status information

Provider Status

Select the status of the provider's license or certification. This field is required.

Resolved

Select this check box to send status information to the provider history.

Reason

Select the reason why the provider's status record is being updated. This field is required.

Other Reason

If you selected Other in the Reason field, you must enter a short description of the reason.

Effective Date

Enter the date on which this status record was in effect. Use the format MM/DD/YYYY. This field is required. You cannot enter a date in the future.

Review Date

Enter the date the provider's status is due to be reviewed. Use the format MM/DD/YYYY. This field is required.

Comments

Enter any further explanation about the provider's status. You can enter up to 200 characters.