Add Provider to My Existing Hospital Group

Please ensure all information is accurate and complete. This form manages provider information for your hospital group. Required field are marked ‘*’

Group Information

Provide your organization's details.

Group Name Required

Please enter a value.

Business Name Required

Please enter a value.

Group NPI Required

Requires 10 numerical characters.

Group TIN Required

Requires 9 numerical characters.

State Required

Primary Location

Provide details about your primary location.

Primary Location Name Required

Please enter a value.

Primary Address Required

Please enter a value.

Primary Phone Required

Invalid phone number.

Primary Fax Required

Invalid phone number.

Billing Location

Provide details about your billing location.

Billing Location Name Required

Please enter a value.

Billing Address Required

Please enter a value.

Billing Phone Required

Invalid phone number.

Billing Fax Required

Invalid phone number.

Provider Information

Provide your provider details.

Provider First Name Required

Please enter a value.

Provider Last Name Required

Please enter a value.

Provider Specialty Required

Please enter a value.

Provider Individual NPI Required

Requires 10 numerical characters.

Effective Date of Addition Required

Must be a valid date. Format: MM/DD/YYYY

Add locations

Manage your locations.

Location 1 Name Required

Please enter a value.

Location 1 Address Required

Please enter a value.

Location 1 Phone Required

Invalid phone number.

Location 1 FAX Required

Invalid phone number.

Location 2 Name Required

Location 2 Address Required

Location 2 Phone Required

Location 2 FAX Required

Location 3 Name Required

Location 3 Address Required

Location 3 Phone Required

Location 3 FAX Required

Location 4 Name Required

Location 4 Address Required

Location 4 Phone Required

Location 4 FAX Required

Location 5 Name Required

Location 5 Address Required

Location 5 Phone Required

Location 5 FAX Required

Location 6 Name Required

Location 6 Address Required

Location 6 Phone Required

Location 6 FAX Required

Location 7 Name Required

Location 7 Address Required

Location 7 Phone Required

Location 7 FAX Required

Location 8 Name Required

Location 8 Address Required

Location 8 Phone Required

Location 8 FAX Required

If you need to add more locations than permitted on this form, please complete another form for the remaining locations.

Completed by

Provide contact information for the person completing this request.

Completed By Name Required

Please enter a value.

Completed By Email Required

Please enter email value in format 'mymail@domain.com'.

Completed By Phone Number Required

Invalid phone number.

Phone Extension (optional) Required

Completed By Comments Required 0/100

Please enter a value.

If you need to add more locations than permitted on this form, please complete another form for the remaining locations.

Add Provider to My Existing Hospital Group

1 Location 1 No information provided

2 Location 2 No information provided

3 Location 3 No information provided

4 Location 4 No information provided

5 Location 5 No information provided

6 Location 6 No information provided

7 Location 7 No information provided

8 Location 8 No information provided