Provider Application Request

Date of Request:

Provider Legal Name:

Do you currently have a contract with Alliance Behavioral Healthcare?

Entity Type:

HospitalAgencyGroupLicensed Independent Practitioner/Solo Practice

Address:

Application Request Contact Information

Contact Name:

Phone:

Email:

Federal Tax ID:

Provider NPI:

Taxonomy:

Is NPI and site registered in NCTracks? Yes/No

Requested service(s) and service code(s) to provide to Alliance Consumers:

Identify any specialties and/or information to be considered in request:

Please identify the client population(s) served at each site as follows:

MH AdultSA AdultDD Adult

MH ChildSA ChildDD Child

Do you havean available Psychiatrist DOPNPPA

Requested Site(s) Address for Proposed Service(s):

Comments:

Please e-mail completed form to

Consumer Information Sheet______

Please complete a section for each Alliance Consumer you are currently serving or requesting to serve. Make copies as needed.

Consumer’s Last Name

Consumer’s First Name

Service Codes Requesting to be provided

Date of Birth mm dd yyyy Consumer Address:

Medicaid NumberDate of First Visit

Are you working with Care Coordination Yes No If “Yes”, Care Coordinator’s

for this consumer? Name:

Consumer’s Last Name

Consumer’s First Name

Service Codes Requesting to be provided

Date of Birth mm dd yyyy Consumer Address:

Medicaid NumberDate of First Visit

Are you working with Care Coordination Yes No If “Yes”, Care Coordinator’s

for this consumer? Name:

Consumer’s Last Name

Consumer’s First Name

Service Codes Requesting to be provided

Date of Birth mm dd yyyy Consumer Address:

Medicaid NumberDate of First Visit

Are you working with Care Coordination Yes No If “Yes”, Care Coordinator’s

for this consumer? Name:

Consumer’s Last Name

Consumer’s First Name

Service Codes Requesting to be provided

Date of Birth mm dd yyyy Consumer Address:

Medicaid NumberDate of First Visit

Are you working with Care Coordination Yes No If “Yes”, Care Coordinator’s

for this consumer? Name:

Revised 8.13.15