New Practitioner 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 practitioner is joining your organization or adding a new location to his/her practice in our service area. (Contact Provider Relations for details of our Service area.) Please submit forms for each billing NPI.

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Start Date is Required.
Tax ID is Required.

Practitioner Last Name is Required.
Practitioner First Name is Required.
Credential/Degree is Required.
Birth Date is Required.
Gender is Required.
American Sign Language is Required.
Cultural Competency Training is Required.
Practitioner Email is Required.

License

In-Training/Non-Licensed is Required.
Please list all active licenses for the provider
Practitioner NPI# License Type(s)
Please list in highest to lowest order)
License # License State License Expiration Date

Medicare Indicator is Required.
Medicaid Indicator is Required.

Facilities

Please list all facilities where practitioners will be practicing. Select one as primary location.

Added Facilities
Add New Facility (with Specialty)
Primary
Location
Facility Name* Address* City* State* Zip* Phone* County* Clinical or Referral/
Authorization Fax
Practitioner
Type
Practitioner Status Specialty Taxonomy Code Can an
Appointment
be Regularly
Scheduled?
Hospitalist*


Hospital Admitting Privileges

List all facilities where practitioner has Hospital Admitting Affiliations (Required for MD, DO, NP, and PA)
Facility Name* Address* City* State* Zip*


Billing Name is Required.
Billing Address is Required.
Billing City is Required.
Billing State is Required.
Billing Zip is Required.
Billing NPI is Required.
Taxonomy Code is Required.

Practitioner Employed Indicator is Required.
Accepting New Patients Indicator is Required.

Credentialing Recipient is Required.
Credentialing Address is Required.
Credentialing City is Required.
Credentialing State is Required.
Credentialing Zip is Required.
Credentialing Phone is Required.
Credentialing Fax is Required.

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

*Indicates a required field