Cómo ser un proveedor participante

Use this form to add a new practice or a new provider within a practice.

General information

Credentialing contact

First name

Last name

Contact phone number

Applying as Select onePrimary Care ProviderEspecialistaMultiple SpecialtiesHDODentist

Credentialing contact email address

Primary practice information

Start work date (at practice)

Group name/Provider name

Street address 1 (Where the physician will be rendering services)

Street address 2

Ciudad

Estado Select oneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Código postal

Phone number

Provider email address

Type 2 group NPI number

Tax information

Tax Identification Number (TIN)

Confirm Tax Identification Number

Hours working as a PCP at primary location

Sunday start time

Sunday end time

Sunday total hours

Monday start time

Monday end time

Monday total hours

Tuesday start time

Tuesday end time

Tuesday total hours

Wednesday start time

Wednesday end time

Wednesday total hours

Thursday start time

Thursday end time

Thursday total hours

Friday start time

Friday end time

Friday total hours

Saturday start time

Saturday end time

Saturday total hours

Total hours per week

Credentialing contact mailing address

Same as physical address

Street address 1

Street address 2

Ciudad

Estado SeleccioneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Código postal

New providers

First name

Last name

Date of birth (YYYY-MM-DD)

Title

Type 1 individual NPI number

CAQH ID#

Primary specialty

Secondary specialty

Name of supervising physician (if applicable)

Additional information

Do you use an electronic medical record in your practice?

Sí

No

If yes, which type do you use? - Select -AcrendoAllscriptsAmazing ChartsAthenaCare TrackereCWeMD EHREpicHealth FusionIntergyKareoMeditechMednet Med SolutionsNextGenNo InfoPractice FusionPrognosisSageSevocityTermedOtro

Is your practice an NCQA certified Patient Centered Medical Home (PCMH)?

Sí

No

Are you a participating provider in an Accountable Care Organization (ACO)?

Sí

No

Do you operate a concierge style practice which requires your patients to pay a periodic retainer fee for any of your services or do you intend to operate a practice in this manner in the future?

Sí

No

Please explain the structure:

Do you participate as a New England Health Plan PCP in another state?

Sí

No

Which state? - None -Rhode IslandMassachusettsNew HampshireConnecticutMaine