Service Centers // Provider Center

Add Location to Existing Ancillary Facility

Group Information

Required
Required
Required
Required
Required

Completed By

Required
Required
Required
Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 1

Required
Required
Required
Example: (555) 555-5555 or 555-555-5555
Required
Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 2

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 3

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 4

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 5

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 6

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 7

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 8

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 9

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 10

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555
If you need to add more locations than permitted on this form, please complete another form for the remaining locations.