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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.

Pharmacist - Ambetter Only

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Please select Provider type required * Solo Practice Group Practice

Error: Provider Type is required.

Administration of Medications, Biologics, and Vaccines

Administration of Medications, Biologics, and Vaccines required * Yes No

Error: Administration of Medications, Biologics, and Vaccines Information is required.

Upload CE Certification Certificate *

Error: CE Certification Certificate upload is required.

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

Board Certified Protocols

Please identify all Board Certified Protocols that the provider has attestation. (Select All That Apply) Acute Group A Streptococcal (GAS) Pharyngitis Infection Protocol v5 Acute Influenza Infection: Antiviral Therapy Protocol Alcohol Use Disorder Protocol utilizing Naltrexone-based Therapy Colorectal Cancer (Crc) Screening Protocol Acute, Uncomplicated Urinary Tract Infection Treatment Protocol Tuberculin Skin Testing One-Step Protocol Tuberculin Skin Testing Two-Step Protocol: For initial testing in adults who will be undergoing annual testing Opioid Use Disorder Protocol Utilizing Naltrexone-Based Therapy

Error: Board Certified Protocol is required.

Please attach all attestations for each Board Certified Protocol selected.

Upload attestation for: Acute Group A Streptococcal (GAS) Pharyngitis Infection Protocol *

Error: Form upload is required.

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

Upload attestation for: Acute Influenza Infection: Antiviral Therapy Protocol *

Error: Form upload is required.

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

Upload attestation for: Alcohol Use Disorder Protocol utilizing Naltrexone-based Therapy *

Error: Form upload is required.

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

Upload attestation for: Colorectal Cancer (Crc) Screening Protocol *

Error: Form upload is required.

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

Upload attestation for: Acute, Uncomplicated Urinary Tract Infection Treatment Protocol *

Error: Form upload is required.

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

Upload attestation for: Tuberculin Skin Testing One-Step Protocol *

Error: Form upload is required.

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

Upload attestation for: Tuberculin Skin Testing Two-Step Protocol *

Error: Form upload is required.

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

Upload attestation for: Opioid Use Disorder Protocol Utilizing Naltrexone-Based Therapy *

Error: Form upload is required.

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

Please populate the fields below:

Effective Date *

Error: This field is required.

Provider First Name *

Error: Provider First Name is required.

Provider Last Name *

Error: Provider Last Name is required.

Practitioner Type *

Error: Practitioner 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 required * 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.

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.

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: Fax Number is required.

Are Lab Services performed at this location? Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

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: Fax Number is required.

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

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

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: Fax Number is required.

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

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

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: Fax Number is required.

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

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

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: Fax Number is required.

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

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

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: Pay To 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 attach the documents listed below. * Attachments that may be 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)
CE Certificate - Administration of Medications, Biologics and Vaccines
Board Protocols Attestation
CLIA Certificate

Please provide any additional information

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: Provider Enrollment Letter upload is required.

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

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