Independent Provider Application

INDEPENDENT PROVIDER APPLICATION

1. GROUP INFORMATION
Legal Name of Group (As applicable):
DBA Name of Group (As applicable):
Tax ID (Must match W-9):
Group Email:
Group Type: General Rehab Independent Provider
Type of Services Provided: ST OT PT Other:
2. PRIMARY SERVICE LOCATION
Practice Address:
City, State, Zip Code:
Phone: / Fax:
County:
Business Days and Hours of Operation:
3. MAILING ADDRESS
Mailing Address same as above? Yes No (If No, complete information below)
Mailing Address:
City, State, Zip Code:
Phone: / Fax:
4. BILLING ADDRESS
Billing Address same as Practice Address? Yes No (If No, complete information below)
Billing Address:
City, State, Zip Code:
Phone: / Fax:
5. SERVICES INFORMATION
Accepting New Patients: Yes No / Any Practice Limitations: None Yes, see below:
Male Only Female Only Age: Other:
6. PROVIDER INFORMATION
First Name: Middle Name:
Last Name: Maiden Name:
Professional Provider Type: SLP OT PT / License #:
Effective Date of License (mm/dd/yyyy): //
Expiration Date of License (mm/dd/yyyy): //
Social Security Number: -- / Date of Birth (mm/dd/yyyy): //
Individual NPI: / Individual TPI:
Taxonomy Code: / CAQH # (If applicable):
Non-English Languages Spoken: Spanish Other:
7. CURRENT INSURANCE/PROFESSIONAL LIABILITY COVERAGE
Current Carrier Name (not agency):
Policy Number: / Agency Phone Number:
Effective Date: // / Expiration Date: //
Occurrence Amount: $ / Aggregate Amount: $
8. CREDENTIALING CONTACT INFORMATION
Contact Name: / Contact Title:
Phone: / Fax:
Email:
ADDITIONAL PRACTICE LOCATIONS
Practice Address:
City, State, Zip Code:
Phone: / Fax:
Business Days and Hours of Operation:
Individual TPI for Additional Location:
Practice Address:
City, State, Zip Code:
Phone: / Fax:
Business Days and Hours of Operation:
Individual TPI for Additional Location:
Practice Address:
City, State, Zip Code:
Phone: / Fax:
Business Days and Hours of Operation:
Individual TPI for Additional Location:
Practice Address:
City, State, Zip Code:
Phone: / Fax:
Business Days and Hours of Operation:
Individual TPI for Additional Location: