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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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




Facilities

Please list all facilities where practitioners 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
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*















*Indicates a required field