Facility Notification

The Facility 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

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Select this option when a new clinic/hospital location needs to be added to an existing participating provider.

Select this option to update information related to an existing participating facility location. Complete this form for changes to the facility phone or fax number, if the facility is relocating and/or there is an address change.

Select this option when a clinic is closing.

New Facility

Billing Information


Accreditation Types

Facility NPI #s/Taxonomy Codes

List facility NPIs and Taxonomy Codes.

Practitioners at this location

List all Practitioners at this location.

Update Facility

Location Information

Billing Information

Terminate Facility

Where are practitioners relocating?

List all Practitioners relocating.

Practitioners Terming at this location

List all Practitioners terming at this location.

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