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Become a Participating Provider
Become a Participating Provider
Practitioner Specialty Purpose Form
  • Clinical Psychologist [PhD; PsyD]
  • Licensed Behavioral Analyst [ABA]
  • Licensed Clinical Social Worker [LCSW]
  • Licensed Marriage & Family Therapist [LMFT]
  • Licensed Mental Health Counselor [LMHC]
  • MD/DO ‐ Psychiatry only (all other MD/DO specialties, see below)
  • Nurse Practitioner, Psychiatry [PMHNP]
  • Enrolling a new practitioner who requires credentialing
  • Changing/adding Tax ID
  • Changing Group Name

Application for Practitioner Enrollment-C (PDF)

To see credentialing requirements for all specialties, click here

  • Anesthesiologist
  • Certified Diabetic Educator (affiliated with Physician Group or Hospital)
  • Certified Registered Nurse Anesthetists [CRNA]
  • Emergency Room
  • Hospitalist
  • Locum Tenens
  • Pathologist
  • Registered Dietician (affiliated with Physician Group or Hospital)
  • Enrolling a new practitioner who does not require credentialing
  • Changing/adding Tax ID

Application for Practitioner Enrollment (PDF)

 

To see credentialing requirements for all specialties, click here

  • Acupuncturist [LAC]
  • Audiologist [AuD]
  • Certified Diabetic Educator [CDE] (Independent)
  • Doctor of Chiropractic [DC]
  • Doctor of Podiatry [DPM]
  • Enterostomal Therapy
  • Medical Doctor [MD/MBBS/BMED]
  • Nurse Practitioner, Primary Care [NP]
  • Certified Nurse Midwife [CNM]
  • Certified Nurse Midwife – Home Birth [CNM]
  • Occupational Therapist [OT]
  • Doctor of Optometry [OD]
  • Oral Maxillofacial Surgery [DMD]
  • Osteopathic Doctor [DO]
  • Registered Dietician [RD] (Independent)
  • Physical Therapist [PT]
  • Speech Pathologist [SLP]
  • Enrolling a new practitioner who requires credentialing
  • Changing/adding Tax ID
  • Changing Group Name
  • Certified Behavior Analyst Assistant
  • Nurse Practitioner
  • Physician Assistant
  • Registered Nurse First Assistant
  • Enrolling a new practitioner working under the supervision of a physician.
  • Already enrolled and updating demographic information, i.e. Supervising Physician, Tax ID, address, etc.
Application for Non-Physician Health Care Practitioner (PDF)
  • General
  • Endodontist
  • Oral Maxillofacial Surgery
  • Orthodontist
  • Pediatric Dentist
  • Periodontist
  • Prosthodontist
  • Enrolling a new practitioner
Application for Dental Enrollment (PDF)
  • Practitioner Name
  • Address, telephone/fax number, ie. Primary Office, Billing, Correspondence, Remittance
  • Terminate a practitioner1
  • Already enrolled and have changes to your practice
Practitioner Demographic Changes

1Terminating a Licensed Physician: Any nurse practitioner (NP), physician assistant (PA), or certified behavior analyst assistant that has a collaborating relationship with the terminated licensed physician must complete an Application for Non-Physician Health Care Practitioner to be reassigned.