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