Practitioner Notification Form

The Practitioner Notification Form is for our participating providers that are currently in our network. If your facility is interested in joining our network, please complete the Provider Participation Request Form.

This form should be used when a practitioner is joining or leaving your organization, adding or terminating a practice location, or has other demographic changes such as name, licensure, in directory or accepting new patients indicators.

We recommend using one of the following browsers: Chrome, Edge, or Firefox to complete the Facility Notification Forms.

For changes specific to facilities such as notifying us of a facility closure, updating a facility address, phone, or fax number, please use the Facility Notification Form. This form is only intended for practitioner notifications.


Need help filling out this form?

Select this option if a practitioner is joining your organization.


Select this option if an existing practitioner with your organization is adding or terming a practice location, when a practitioner changes their name, specialty, degree/credentials, licensure, or status at a practice location such as no longer accepting new patients.


Select this option if an existing practitioner is completely terminating from your organization for all practice locations.



Add Practitioner

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License

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Please list all active licenses for the provider

Please list in highest to lowest order)

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Facilities

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

Added Facilities
Add New Facility (with Specialty)
Primary
Location
Facility Name* Address* City* State* Zip*
County* Phone* Clinical or Referral/
Authorization Fax*
Practitioner
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Practitioner Status* Specialty* Taxonomy Code*
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Hospital Affiliations

List all hospitals where the practitioner has privileges to examine, treat, and manage patients as outpatient or inpatient within the hospital.


Practitioner's Billing Information

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Updating Practitioner
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Facilities

Please list new facilities where practitioner will be practicing.

Added Facilities
Facility (with Specialty)
Primary
Location
Facility Name* Address* City* State* Zip*
County* Phone* Clinical or Referral/
Authorization Fax*
Practitioner
Type*
Practitioner Status* Specialty* Taxonomy Code*

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Please list all facilities that the practitioner is terming from


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License
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Please list all active licenses for the provider

Please list in highest to lowest order)

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Hospital Affiliations
List all hospitals where the practitioner has privileges to examine, treat, and manage patients as outpatient or inpatient within the hospital.

Terminating Practitioner
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Contact Name is Required.
Contact Email is Required.
Contact Phone is Required.

*Indicates a required field