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Provider Center
Join Our Network Form - Ancillary/Facility
Please complete the questionnaire for our Provider Relations team.
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
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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
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: