Provider Demographic Document
Provider Information
Note : Fields marked with a red star * are required mandatory      
Provider Last Name : * Provider First Name : *
M.I. : * Gender : *
Degree : * Medicaid : *
Practice Category :  * Medicare : *
NPI : * NPI-Related Taxonomy Codes : *
CAQH : * Date of Birth : *
Email Address : *    
Number of FTE Physicians Extenders Used in Office : * Wheelchair Access : *
       
Practice Information
Primary Office    
Type of Practice : * Practice Name (if any) : *
Address : * City : *
Zip : * State : *
Telephone number : * Fax : *
   
Working Hours : *    
Monday: To :                     From :                            
Tuesday: To :                     From :                            
Wednesday: To :                     From :                            
Thursday: To :                     From :                            
Friday: To :                     From :                            
Saturday: To :                     From :                            
Sunday: To :                     From :                            
   
Secondary Office    
Type of Practice : Practice Name (if any) :
Address : City :
Zip : State :
Telephone number : Fax :
   
Working Hours :  
Monday: To :                     From :                            
Tuesday: To :                     From :                            
Wednesday: To :                     From :                            
Thursday: To :                     From :                            
Friday: To :                     From :                            
Saturday: To :                     From :                            
Sunday: To :                     From :                            
   
Alternate Office    
   
Type of Practice : Practice Name (if any) :
Address : City :
Zip : State :
Telephone number : Fax :
   
Working Hours :    
Monday: To :                     From :                            
Tuesday: To :                     From :                            
Wednesday: To :                     From :                            
Thursday: To :                     From :                            
Friday: To :                     From :                            
Saturday: To :                     From :                            
Sunday: To :                     From :                            
   
Billing Information
Primary Office Billing Info      
Payee Name : * Remittance Address :  *
City : * State : *
Telephone :  * Fax : *
Tax ID : * Zip Code : *
Secondary Office Billing Info      
Payee Name : Remittance Address :
City : State :
Telephone : Fax :
Tax ID : Zip Code :
Alternate Office Billing Info      
Payee Name : Remittance Address :
City : State :
Telephone : Fax :
Tax ID : Zip Code :
       
New Provider Demographic Attestation
       
Specialty : Primary Practice : Specialty : Secondary Practice :
I am a Specialist Provider. I attest that I understand that I am not practicing as a Primary Care Provider even if I am trained or board certified in a Primary Care Provider designated specialty.
 
I am a Primary Care Provider. I attest that I may be assigned a patient panel and may be chosen by plan members as their Primary Care Provider. I attest that I understand that I am not practicing as a Specialist Provider even if I am trained or board certified in a Specialist designated specialty.
 
I am a Dual Practice Provider. I attest that I am a Primary Care Provider and as such, I may have a patient panel assigned to me or I may be chosen by a plan member as their Primary Care Provider. I further attest that I am also a Specialist Provider and may have referrals made to me in my chosen specialty.
 
I am an Allied Health Provider. I attest that I am neither, a Primary Care or Specialist Physician Provider.
 
Check if you agree with all the answers in this form      
       
Provider NPI: Your Full Name:
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