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National Ancillary Solution
ACS - Join as New Ancillary/Facility
Provider Information
Group Name:
Required
Business Name (DBA):
Required
Main Practice Address:
Required
City:
Required
State:
Required
AK
AL
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
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NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
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Zip:
Required
Main Practice Location Phone:
Required
Example: (555) 555-5555 or 555-555-5555
Main Practice Email:
Required
TIN:
Required
NPI:
Required
Number Of Practice Locations:
Required
Number Of Providers In Group:
Required
I am interested in delegation:
I wish to be considered as a national provider:
Ancillary/Facility Type:
Required
Ambulatory Surgery Center (ASC)
Diagnostic Imaging Center/MRI - HCFA (DIHCFA)
Diagnostic Imaging Center/MRI - UB (DIUB)
Durable Medical Equipment/Orthotics Prosthetics (DME)
Home Health Agency/Hospice (HH)
Home Infusion Therapy (HI)
Long Term Acute Care/Rehab (LTACH)
Independent Laboratory (LAB)
Psychiatric/Substance Abuse/IOP Facility (PSYCH)
Skilled Nursing Facility (SNF)
Specialty Pharmacy (PHA)
Other
Ancillary/Facility Type If Other:
Billing/Coding Information - Please Select All That Apply
HCFA
UB
Inpatient
Outpatient
CPT Codes
HCPC Codes
Rev Codes
Credentialing Information
Contact Name:
Required
Contact Phone:
Required
Example: (555) 555-5555 or 555-555-5555
Extension:
Contact Email:
Required
Form Completed By
Completed By Name:
Required
Completed By Email:
Required
Completed By Phone:
Required
Example: (555) 555-5555 or 555-555-5555
Extension:
Comments: