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Add a Practitioner to an Existing Contract or Location

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.

Behavioral Health Practitioner

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Please select Practice type required * Solo Practice Group Practice

Error: Practice Type is required.

Please select Group Practice type: required * BHSO - Behavioral Health Service Organization BHMSG - Behavioral Health Multi-Specialty Group CDTC - Chemical Dependency Treatment Center CMHC - Community Mental Health Center Independent BH Provider Residential Crisis Stabilization Unit

Error: Group Practice Type is required.

Please populate the fields below:

Effective Date *

Error: This field is required.

Practitioner First Name *

Error: Practitioner Name is required.

Practitioner Last Name *

Error: Practitioner Name is required.

Practitioner Type *

Error: Provider Type is required.

CAQH ID # *

Error: CAQH ID # is required.

NPI *

Error: NPI is required.

Medicaid Number *

Error: Medicaid Number is required.

Medicare Number *

Error: Medicare Number is required.

License Number *

Error: License Number is required.

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

Error: Line of Business is required.

CLIA Number (Only applicable for physician, APRN, physician assistant)

Group Name *

Error: Group Name is required.

Tax Identification Number *

Error: Tax Identification Number is required.

Group NPI *

Error: Group NPI is required.

Practitioner Race, Ethnicity, and Language Information (Optional)

We encourage providers to voluntarily share their race, ethnicity, and language (REL) information. This information helps us better understand the diversity and language capabilities of our provider network and evaluate how well our network aligns with the needs and preferences of our members. Completion of the REL section is voluntary. The information provided will not be used in credentialing, participation, contracting, reimbursement, or any other provider eligibility determination. You may choose "Prefer not to answer" for any question.

Race (Select All That Apply)

Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race (Please Specify) Prefer not to Answer

Error: This field is required.

Other Race *

Error: This field is required if Other box is checked

Ethnicity

Ethnicity Not Hispanic or Latino Other Ethnicity (please specify) Prefer not to answer

Error: This field is required.

Other Ethnicity *

Error: This field is required if Other box is checked

Languages Spoken by Practitioner (Select All That Apply)
Select only the languages in which the practitioner can personally provide services without an interpreter.

Languages Spoken by Practitioner (Select All That Apply) English Spanish Arabic Chinese (Mandarin) Chinese (Cantonese) French German Hindi Korean Russian Tagalog Vietnamese Other (Specify) Prefer not to answer

Error: This field is required.

Other Languages *

Error: This field is required if Other box is checked

Preferred Language for Patient Care
Select the practitioner's preferred language for providing patient care.

Preferred Language for Patient Care

Other Preferred Language *

Error: This field is required if Other box is checked

Do you offer services directly in the Preferred Language selected above without an interpreter? Yes No

Error: This field is required.

Does the practitioner routinely use qualified interpreter services when providing care in a language the practitioner does not speak? Yes No

Error: This field is required.

Primary Office/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: City 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 (Only applicable for physician, APRN, physician assistant)

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.

Additional Locations - Please list alternate and/or covering-only locations below. One practitioner can have up to 5 covering locations.

Number of addtional locations

Additional Location 1

Practice Location Name

Street Address

City

State

Zip Code

Error: Zip Code is required.

County

Phone Number

Error: Phone Number is required.

Fax Number

Error: This field is required.

Are Lab Services performed at this location? Yes No

Error: This field is required.

CLIA Number (Only applicable for physician, APRN, physician assistant)

CLIA Expiration

Error: This field is required.

OPT out of Directory (Address will be listed in directory as long as provider is at this location 16 hours or more) Yes No

Error: This field is required.

Covering Location (Covering locations are not included in the directory) Yes No

Error: This field is required.

Additional Location 2

Practice Location Name

Street Address

City

State

Zip Code

Error: Zip Code is required.

County

Phone Number

Error: Phone Number is required.

Fax Number

Error: This field is required.

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

Error: Lab Services response is required.

CLIA Number (Only applicable for physician, APRN, physician assistant)

CLIA Expiration

Error: This field is required.

OPT out of Directory (Address will be listed in directory as long as provider is at this location 16 hours or more) Yes No

Error: This field is required.

Covering Location (Covering locations are not included in the directory) Yes No

Error: This field is required.

Additional Location 3

Practice Location Name

Street Address

City

State

Zip Code

Error: Zip Code is required.

County

Phone Number

Error: Phone Number is required.

Fax Number

Error: This field is required.

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

Error: Lab Services response is required.

CLIA Number (Only applicable for physician, APRN, physician assistant)

CLIA Expiration

Error: This field is required.

OPT out of Directory (Address will be listed in directory as long as provider is at this location 16 hours or more) Yes No

Error: This field is required.

Covering Location (Covering locations are not included in the directory) Yes No

Error: This field is required.

Additional Location 4

Practice Location Name

Street Address

City

State

Zip Code

Error: Zip Code is required.

County

Phone Number

Error: Phone Number is required.

Fax Number

Error: This field is required.

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

Error: Lab Services response is required.

CLIA Number (Only applicable for physician, APRN, physician assistant)

CLIA Expiration

Error: This field is required.

OPT out of Directory (Address will be listed in directory as long as provider is at this location 16 hours or more) Yes No

Error: This field is required.

Covering Location (Covering locations are not included in the directory) Yes No

Error: This field is required.

Additional Location 5

Practice Location Name

Street Address

City

State

Zip Code

Error: Zip Code is required.

County

Phone Number

Error: Phone Number is required.

Fax Number

Error: This field is required.

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

Error: Lab Services response is required.

CLIA Number (Only applicable for physician, APRN, physician assistant)

CLIA Expiration

Error: This field is required.

OPT out of Directory (Address will be listed in directory as long as provider is at this location 16 hours or more) Yes No

Error: This field is required.

Covering Location (Covering locations are not included in the directory) Yes No

Error: This field 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.

Phone Number *

Error: Primary Contact Phone Number is required.

Email *

Error: Primary Contact Email is required.

Credentialing Contact Name *

Error: Credentialing Contact Name is required.

Phone Number *

Error: Credentialing Contact Phone Number is required.

Email *

Error: Credentialing Contact Email is required.

Please provide any additional 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 - Practitioner (PDF)
Provider Erollment Letter - advising of specific details of the enrollment request. (On your company letterhead)

Disclosure of Ownership Form

Items in the trash will be permanently removed after 30 days.

W-9 Form *

Error: W-9 Form upload is required.

Items in the trash will be permanently removed after 30 days.

LOAP/Practitioner Roster Form

Items in the trash will be permanently removed after 30 days.

Copy of Current Malpractice Certificate of Insurance *

Error: Copy of Current Malpractice Certificate of Insurance upload is required.

Items in the trash will be permanently removed after 30 days.

CVO Credentialing Form - Practitioner (Completion of this form is required only in the absence of a CAQH profile.)

Items in the trash will be permanently removed after 30 days.

Provider Enrollment Letter - advising of specific details of the enrollment request. (On your company letterhead) *

Error: Provider Enrollment Letter upload is required.

Items in the trash will be permanently removed after 30 days.

CLIA Certificate *

Error: CLIA Certificate upload is required.

Items in the trash will be permanently removed after 30 days.

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