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Add a Facility Request Form

Ancillary

Instructions for adding a facility to an existing contract.

Back to primary service type selections

To ensure your request can be processed, please make sure all required fields and data are fully completed and accurate. Additionally, all necessary documents must be attached and complete. Requests submitted with missing information will result in your request being discarded. Your provider representative will be informed of the missing information and will reach out to notify you. Once you are able to provide the necessary information, please resubmit your request using this online form.

Please select Provider type required *

Please populate the fields below:

Line of Business (Please select all that apply) required *

Primary Office/Service Address Information.

Are Lab Services performed at this location? required *
Include in Provider Directory required *
Do you offer Telemedicine Services? required *
Do you participate with KHIE (Kentucky Health Information Exchange)? required *

Correspondence Address

Pay To Information

Your Contact Information

Please attach the documents listed below.  *Attachments required for submission.

  • Disclosure of Ownership Form*
  • W-9 Form*
  • LOAP/Practitioner Roster Form (XLS)
  • Copy of Current Malpractice Certificare of Insurance*
  • CVO Credentialing Form - Facility (PDF)*
  • Provider Erollment Letter advising of specific details of the enrollment request. (On your company letterhead)
  • Facility Licensure*
  • CLIA Certificate (Required if Lab Services performed at location)
  • Accreditation per approved Centene Accrediting Institution
  • Other