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Become a Provider

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Add a Facility Request Form

Behavioral Health Facility

Instructions for adding a facility to an existing contract.

Back to primary service type selections

Please select Provider type required * BHSO - Behavioral Health Service Organization BHMSG - Behavioral Health Multi-Specialty Group CDTC - Chemical Dependency Treatment Center CMHC - Community Mental Health Center CCBHC - Certified Community Behavioral Health Clinic PRTF - Psychiatric Residential Treatment Facility Residential Crisis Stabilization Unit

Error: Provider Type is required.

Is the facility ASAM Certified? required * Yes No

Error: Group Provider is required.

Please populate the below.

Provider Name *

Error: Provider Name is required.

NPI *

Error: NPI is required.

Medicaid Number *

Error: Medicaid Number is required.

Medicare Number *

Error: Medicare Number is required.

License Number *

Error: Provider Name is required.

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

Error: Line of Business is required.

Group Name *

Error: Group Name is required.

Tax Identification Number *

Error: Tax Identification Number is required.

Group NPI *

Error: Group NPI is required.

Facility/Group Service Address Information.

Practice Location Name *

Error: Practice Location Name is required.

Street Address *

Error: Street Address is required.

City *

Error: City is required.

State *

Error: State is required.

Zip Code *

Error: Zip Code is required.

County *

Error: County is required.

Phone Number *

Error: Phone Number is required.

Fax Number *

Error: Fax Number is required.

Are Lab Services performed at this location? required * Yes No

Error: Lab Services response is required.

CLIA Number *

Error: CLIA Number is required.

CLIA Expiration *

Error: CLIA Expiration is required.

Include in Provider Directory required * Yes No

Error: Provider Directory Inclusion choice is required.

Do you offer Telemedicine Services? required * Yes No

Error: Telemedicine Services information is required.

Do you participate with KHIE (Kentucky Health Information Exchange)? required * Yes No

Error: KHIE information is required.

Correspondence Address

Contract Entity Name *

Error: Contract Entity Name is required.

Street Address *

Error: Street Address is required.

City *

Error: City is required.

State *

Error: State is required.

Zip Code *

Error: Zip Code is required.

County *

Error: County is required.

Phone Number *

Error: Phone Number is required.

Fax Number *

Error: Fax Number is required.

Pay To Information

Pay To Name *

Error: Pay To Name is required.

Street Address *

Error: Pay To Address is required.

City *

Error: Pay To City is required.

State *

Error: State is required.

Zip Code *

Error: Pay To Zip Code is required.

Your Contact Information

Primary Contact Name *

Error: Primary Contact Name is required.

Email *

Error: Primary Contact Email is required.

Phone Number *

Error: Primary Contact Phone Number is required.

Credentialing Contact Name *

Error: Credentialing Contact Name is required.

Email *

Error: Credentialing Contact Email is required.

Phone Number *

Error: Credentialing Contact Phone Number is required.

Please provide any additional information

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

ASAM Certification (BHSO - ASAM Certified)
Disclosure of Ownership Form^*
W-9 Form^*
LOAP/Practitioner Roster Form (XLS)
Copy of current Malpractice Certificate of Insurance^*
CVO Credentialing Form - Facility: Facility: BHSO, CDTC, CMHC, CCBHC, PRTF, Residential Crisis Stabilization Unit (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)