New Location Form

These notification forms are for our participating providers that are currently in our network only. If you are interested in joining our network please complete the Provider Participation Request Form

This form should be used when a new clinic / hospital location needs to be added, or a clinic is relocating to a new address (also complete the Location Termination Form). If brand new practitioners are being added to this location, please use the New Practitioner Form.

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Effective Date is Required.
Provider Directory is Required.

Location Name is Required.
Address is Required.
City is Required.
State is Required.
Zip Code is Required.
County is Required.

Mail Acceptance is Required.
Format: XXX-XXX-XXXX
Clinic Phone is Required.
Format: XXX-XXX-XXXX
Clinic Fax is Required.

Clinic Manager Name is Required.
Format: XXX-XXX-XXXX
Business Phone is Required.
Format: XXX-XXX-XXXX
Business Fax is Required.
Clinic Manager Email is Required.

Billing Tax ID is Required.
Billing Contact Name is Required.
Billing Name for Services is Required.
Billing Address is Required.
Billing City is Required.
Billing State is Required.
Billing Zip is Required.
Format: XXX-XXX-XXXX
Billing Phone is Required.
Format: XXX-XXX-XXXX
Billing Fax is Required.
Billing Email is Required.

After Hours Coverage is Required.
Office Hours is Required.

Facility NPI #s/Taxonomy Codes:*
Facility NPI# Service Type Taxonomy Code Billing NPI


Practitioners at this location:*
Practitioner Practitioner NPI


Contact Name is Required.
Contact Email is Required.
Format: XXX-XXX-XXXX
Contact Phone is Required.

*Indicates a required field