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 separate forms for each billing NPI.

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License
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:*
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Facilities
Please list all facilities where pracitioners will be practicing. Select one as primary location.

Add New Facility (with Specialty)
Primary
Location
Facility Name* Address* City* State* Zip* Phone* County* Clinical or Referral/
Authorization Fax
 
Practitioner
Type
Available
to Choose
as PCP?
Practitioner Status Specialty Taxonomy Code Appointments
Regularly
Scheduled?
Hospitalist








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Hospital Admitting Privileges
List all facilities where practitioner has Hospital Affiliations (Required for MD, DO, NP, and PA)

Facility Name* Address* City* State* Zip*
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Please submit separate forms for each billing NPI






















* Indicates a required field.