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Accessible staffing print out application form

hello and welcome to one of our many Pickers demonstrations in this demonstration we will be walking you through the process of submitting an application and Pecos if you are a practitioner providing healthcare services and work in a group setting like a private practice or a hospital in order to begin this application we'll have to log into the Pecos homepage to obtain your login credentials and find other helpful information regarding Medicare and the application process please visit the Pecos homepage please note that if you are a practitioner working in the setting other than what we've just described or have some other business arrangement the steps for beginning your application are identical to what we'll be showing here and the process of enrolling will have many of the same screens shown in this demonstration entering user ID and password selected login button after logging in you'll need to select this my enrollments button here first and because we're now creating a new application for the practitioner Jenny Lewis you'll want to select this new application button here after doing this you will be prompted to answer a series of questions to help personalize the application to your specific scenario you'll first need to indicate who the application is being created for so here you'll select yourself and select the next page button to continue on this screen you're being prompted to enter whether or not you as the practitioner solely order and refer services so for the purpose of this demonstration I'm going to select no and continue on this screen you will be selecting the business setting in which you work because this demonstration is for a provider working in a group setting we'll be selecting the group member only field shown here I'll go ahead and scroll down and select the next page button to continue here your identifying information will be displayed to you as a label so you can go ahead and select the next page button now you'll then need to indicate the state where health care services are rendered so for this example the practitioner works and provides services in Arizona that's what we'll select and then move on by clicking the next page button at the bottom of the screen and here you'll indicate your physician or non physician specialty type so in this example Jenny Lewis practices internal medicine so we'll select that from the drop-down and then move forward with the next page button at the bottom of the screen you'll then be brought to a page which simply serves to inform you that the provider group you work for must already be enrolled in Medicare so please ensure that this is the case before continuing your application and if you'd like to continue you'll just select this yes option here and move forward finally we've completed the initial set of questions for this enrollment and you can then verify at the top of the screen that the information presented here is correct for your situation in this example the practitioner isn't rolling indeed for the first time so you can scroll down to the bottom of the page after verifying and start this initial annulment by selecting that start application button shown here at this point in time we are now ready to begin completing each of the sections needed to submit the Medicare form before beginning the application please note some key features located at the top of the page first there's a progress bar shown here which indicates how close you are to completing your enrollment application and being able to scroll down to the bottom of the page and selecting this begin submission button additionally there are three tabs located at the top of the page to help you in browsing first is the topic view page which is the page we're on right now and conveniently gives you a high-level view of what needs to be completed in your enrollment application by showing checkmarks next two sections that are already done the fast-track view on the second tab here shows all of these sections also within one page including the information you've already entered easily accessible simply by selecting this go to topic button here and then lastly there's the error slash warning check tab which shows you what is still outstanding to be completed with your within your application and any errors the system finds and what you've entered note the red number shown here in the tab and that that will decrease as you address each item that's listed here as an error I'm now going to navigate by selecting this topic View tab here there are a number of sections that still need to be addressed and completed before I can move forward by selecting this begin submission button these sections can be done in any order and so for the purpose of this demonstration I'll start by walking you through the first section the personal information section and I'll do that by selecting this hyperlink now to complete this section you'll need to start by selecting the add information button here you'll then see some personal identifying information shown as labels and you'll need to complete the rest of the remaining required field shown here with a red asterisk I'll then select the next page button to continue here you'll be able to provide any additional names to Medicare like a former maiden name or professional name for the purpose of this demonstration I'm going to select know that there are no other names that I'd like to report and click on the next page button at the bottom of screen you'll then be able to enter any drug enforcement agency or DEA numbers and if you do not have this information you can move forward because it is optional by simply selecting the next page button you'll then indicate birth location information and I'll select Arizona and move forward next page on this page you'll then be able to indicate the medical school or professional school that you obtain your medical degree and then also be able to indicate the year of graduation after entering this information you can select next page button to move forward finally you'll be brought to the IRS proprietary slash nonprofit status page where you can indicate how the business is registered with the IRS in this example since we're enrolling as a group member I'm not going to enter this information is in here I'll just instead select the Save button to move forward you'll then be brought to this topic summary screen where you'll see all of the information you entered here as a label and if you need to make any updates at this time you can do so by selecting this edit button here since I'm satisfied with this information I'm going to return to my topics by selecting this return to topics button at the bottom of the screen as you can see the personal information section now has a checkmark next to it for the purpose of this demonstration I'm going to go ahead and complete most of the remaining sections missing in this enrollment application in order to show you the submission piece of your enrollment in Pecos so now I've gone ahead and entered in almost all of the missing information needed in order to scroll down to the bottom of the page and select this begin submission button shown here you'll see though that if I scroll up here there's one section here still missing a check mark the required and/or supporting documentation section and all the way at the top of the page the error slash warning check tab still indicates that there's one missing piece left to my enrollment application that needs to be addressed so I'll select this error slash warning check tab and you'll see here that the error is that an indication on required and/or supporting documentation needs to be made so we'll navigate directly to that section now by selecting this hyperlink here and you'll then be pulled into this required and/or supporting documentation section where you can indicate whether or not you as the applicant wish to upload supporting documents to your enrollment so I'm going to select yes that I want to upload some documentation and I'll scroll down to the bottom of the page and you'll see additional helpful information on requirements for this documentation shown here on the screen and now I'll go ahead and select one of these so for the purpose of this demonstration I'll upload a driver's license presenter clicks on the choose file button and a Windows dialog box opens and then I'll select the upload button shown here I'll then scroll down to the bottom of the page and see that this document indeed has been uploaded and has been assigned a unique document ID shown here if you need to view that this information D was uploaded accurately you can do so using the View button and if you need to remove this document because you accidentally uploaded the wrong one simply select this remove button shown here you can go back and repeat the steps just shown to upload different documents instead if you need to i'll next navigate back to the error check tab just to make sure that there are no errors left that I need to address before I can continue with the application and as you can see there are no errors or warnings found for this enrollment so I'll go ahead and select the topic view button now and I'll scroll down to the page and this begin submission button is now enabled so so I'll go ahead and click on that now the first page you are brought to in the submission process is the electronic signature option page where you would be given the opportunity to electronically sign for any documents listed on the screen at this point in time so in this example that includes the certification statement and authorization statement I'm going to select yes that I would like to electronically sign these documents and what this means is that I would not then need to mail them and submit a hardcopy to my Medicare administrative contractor as this would be sufficient so I'll go ahead and select the next page button now the next piece of your submission process is the e-signature submission page will you'll be prompted to review all documentation prior to e signing and then you'll need to scroll down through the page and read each of the terms and conditions for all documents listed here and agree to accept them and so in this example I'll select YES for both the certification statement Terms & Conditions and the authorization statement if you continue to scroll down further to the middle of the page you'll see the signatories for accepting a reassignment section here you'll need to identify an authorized signer for the group that is receiving your reassignment of benefits so I'll select Tony Smith here from this drop down here as my authorized signer and I'll enter Tony's email address now your authorized signer will then receive an email suggesting that they need to go ahead and electronically sign that they accept the reassignment of benefits indicated in this application before your Medicare administrative contractor will be able to begin processing your enrollment record in Pecos and then if you scroll down further to the bottom of the page you'll see this complete your each signature section well you will need to indicate your identifying information and this is what will validate and constitute as your electronic signature for your application and after entering this information here and verifying it for correctness I'll select this next page button to continue you'll then be brought to the contact and processing page we will go over to this drop down here and select your Medicare administrative contractor and select the apply button and as you scroll down on this page you'll then see your reason for submission here as a label other information on required and/or supporting documentation and when you scroll all the way down to the bottom of the page you'll also see the document that you've uploaded to electronically submit with your application if at any point in time in navigating to this page there are any updates you need to make to your application you can still do so at this time by selecting the previous page button here or selecting this upload new slash removed documentation hyperlink if you simply just want to review your document that you've uploaded an ensure that it is indeed correct you can do that without going back into your enrollment by simply selecting this view button here because all of the information on this screen seems accurate and I'm ready to submit my application to Medicare I'll click on this complete submission button now a pop-up will then appear on your screen to notify you that any documentation that you have not uploaded electronically with this application at this time will need to be printed and mailed to your Medicare administrative contractor and any delay in doing this will mean that your application will risk not being processed in a timely manner by your contractor so after you acknowledge this fact you can select the ok button and then you'll be brought to the submission confirmation page where you can print this as a receipt for your personal records congratulations we've now just completed an initial submission to Medicare using Pecos and for any further information on the application process and Medicare itself please visit the Pecos homepage