Insert Letterhead Here: (Preferred)

Form must be submitted at least sixty (60) days prior to effective date.

Submission Date*

Month/Day/Year

Group Name*

Group TIN*

Group NPI (10 numbers)*

Effective Date with Group*

Provider Name*

Provider Email*

Provider Cell Phone No.*

Provider NPI (If pending indicate below)*

CAQH ID (If pending indicate below)*

Individual PTAN (If pending indicate below)*

Primary Specialty*

*If practicing multiple specialties, please list below which is primary, secondary and any additional.

Practice Location Information

Primary Practice Address*

Primary Practice Phone No.*

Primary Practice Fax No.*

List in Directory*

Yes

No

Accepting Patients*

Yes

No

Secondary Location (If applicable)

Secondary Phone No.

Secondary Fax No.

Secondary List in Directory

Yes

No

Secondary Accepting Patients

Yes

No

Additional Locations (If applicable)

Mailing/Correspondence Address

Mailing/Correspondence Address Same as Practice Location*

Yes

No (Please provide information below)

Mailing & Correspondence Address

Correspondence Phone No.

Correspondence Fax No.

Billing/Remittance Address

Billing/Remittance Address Same as Practice Location*

Yes

No (Please provide information below)

Make checks payable to

Payment Address

City

State/Region

Payment Phone No.

Payment Fax No.

Contact Person

Contact Persons Name*

Job Title*

Email*

CV (Must include MM/CCYY under education and work history)*

Practice W-9*

Liability Insurance Face Sheet

Federal DEA Certificate

Board Certification Information

Hospital Privilege Letter or Admitting Arrangement Letter

Physician Profile Picture