New Practitioner Education Form - Neighborhood Health Plan printable pdf download

New Practitioner Education Form - Neighborhood Health Plan

Attention: Provider Services

910 Douglas Pike

Smithfield, RI 02917

Phone: 1-401-459-6020 or 1-800-459-6019

Fax: 1-401-709-7066

New Practitioner Education Form

Please complete this form and return via fax or mail to Neighborhood Provider Services. Address

information above.

Date: _____________ Number of pages (including this cover sheet): _____

Provider Group Name: _________________________ Site Liaison/Contact Name: ______________________

Phone Number: ______________________________ Fax Number: __________________________________

Practitioner Demographic Information

Practitioner Name:

Title (MD, NP, etc.):

Specialty:

Sub-Specialty(s):

Start Date:

Neighborhood ID # (if available):

If the practitioner is not currently credentialed with Neighborhood, please complete Box D.

Previous Practice Information (if available)

Provider Group Name:

Phone Number:

Contact Name:

End Date:

Billing Information

Billing Name:

Billing Address:

Phone Number:

Fax Number:

Contact Name:

Please attach a copy of the W-9 form.

Credentialing Information

Please circle one:

Has the incoming practitioner submitted an application to Neighborhood to date?

YES

Date submitted:

Would you like us to send you a Neighborhood Practitioner Application?

YES

Neighborhood Health Plan of Rhode Island

New Practitioner Education Form - Neighborhood Health Plan