Add a New Provider to a Currently Contracted Practice/Group Please complete the following information to add a new provider in a practice/group that is currently contracted with Neighborhood Health Plan of Rhode Island. If you require a new contract with Neighborhood, please go to the Join our Network web page.Effective Date* MM slash DD slash YYYY Practitioner is enrolled with Rhode Island Medicaid*Practitioner is enrolled with Rhode Island Medicaid *YesNoPractitioner is an Early Intervention (EI) Provider*Practitioner is an Early Intervention (EI) Provider *YesNoPer federal requirements, all providers participating in the Neighborhood network are required to be enrolled with Rhode Island Medicaid. If you are currently not enrolled with Rhode Island Medicaid, please visit the Rhode Island Executive Office of Health and Human Services Provider Enrollment Page for additional information on how to enroll: Rhode Island Medicaid Provider Enrollment Application For questions regarding the enrollment application, please contact EOHHS customer service help desk directly at (800) 964-6211 or (401) 784-8100. Upon successful enrollment with Rhode Island Medicaid, please submit your request to Neighborhood for processing.Group/Entity NPI* Group/Entity Name* Group/Entity TIN* Provider NPI* Provider Name* EthnicitySelect EthnicityAfricanAfrican AmericanAmerican Indian or Alaskan NativeArabicAsianAsian IndianAsian or Pacific IslanderBamarBlackBlack (Non-Hispanic)BosnianBrazilianBurmeseCaucasianChamorroChicanoChineseCubanCuban EthnicityCzechDominicanEast IndianEgyptianEthiopianFilipinoFrenchGermanGhanaianGreekGuamanianHaitianHispanicHispanic EthnicityIndian (India native)IndonesianIranianIraqiIrishItalianJamaicanJapaneseKarenKoreanLatinoMediterraneanMexicanMexican AmericanMexican EthnicityMiddle EasternMutually DefinedNative AmericanNative HawaiianNon-Hispanic EthnicityNot ApplicableNot ProvidedOther Race Or EthnicityPacific IslanderPakistaniPalaniPalestinianPersianPilipino or FilipinoPolishPuerto RicanPuerto Rican EthnicityPunjabiRomanianRussianSamoanSerbianShanSomalianSubcontinent Asia AmericanSudaneseThaiTurkishVietnameseWhite (Non-Hispanic)YemenPrimary Specialty* Secondary Specialty Practice Name* Practice NPI (if applicable) Practice Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Practice Phone*Emergency/Urgent Care Provider*Emergency/Urgent Care Provider *YesNoPhysician Assistant Provider* (If yes, click here to complete the required Physician Assistant Attestation. Save this form to your desktop, complete, and attach/upload to this form below)Physician Assistant Provider *YesNoPA Questionnaire*Accepted file types: pdf, Max. file size: 5 MB.Behavioral Health Provider* (If yes, click here to complete the required Behavioral Health Questionnaire. Save this form to your desktop, complete, and attach/upload to this form below)Behavioral Health Provider *YesNoBH Questionnaire*Accepted file types: pdf, Max. file size: 5 MB.Provider role at this location*Provider role at this location *PCPSpecialistAll providers must submit a Practitioner Attachment. Click here and save this form to your desktop, complete, and attach/upload to this form.Practitioner Attachment to Neighborhood Agreement* Drop files here or Select files Max. file size: 10 MB. Is the provider accepting new patients at this location?*Is the provider accepting new patients at this location? *YesNoDoes the provider offer Telemedicine services?*Does the provider offer Telemedicine services? *YesNoProvider's hours at this location* Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday Hours*Sunday Hours *CustomOpen 24 HoursSunday Open* : Hours Minutes AM PM AM/PM Sunday Close* : Hours Minutes AM PM AM/PM Monday Hours*Monday Hours *CustomOpen 24 HoursMonday Open* : Hours Minutes AM PM AM/PM Monday Close* : Hours Minutes AM PM AM/PM Tuesday Hours*Tuesday Hours *CustomOpen 24 HoursTuesday Open* : Hours Minutes AM PM AM/PM Tuesday Close* : Hours Minutes AM PM AM/PM Wednesday Hours*Wednesday Hours *CustomOpen 24 HoursWednesday Open* : Hours Minutes AM PM AM/PM Wednesday Close* : Hours Minutes AM PM AM/PM Thursday Hours*Thursday Hours *CustomOpen 24 HoursThursday Open* : Hours Minutes AM PM AM/PM Thursday Close* : Hours Minutes AM PM AM/PM Friday Hours*Friday Hours *CustomOpen 24 HoursFriday Open* : Hours Minutes AM PM AM/PM Friday Close* : Hours Minutes AM PM AM/PM Saturday Hours*Saturday Hours *CustomOpen 24 HoursSaturday Open* : Hours Minutes AM PM AM/PM Saturday Close* : Hours Minutes AM PM AM/PM If you are requesting to add the above provider to more than one location, please upload/attach a document that includes, at minimum: Practice Name, Practice NPI (if applicable), Address, Phone, and Fax. Also please indicate whether or not the site is the PCP location. Note: To set-up a new location, use the Add a Practice Location to a Current Group form.Additional Locations File Upload Drop files here or Select files Accepted file types: doc, docx, xls, xlsx, Max. file size: 5 MB. Office Contact Name* Office Contact Email Address* Details for person submitting the formName* Title* Phone Number*Email* Date* MM slash DD slash YYYY CAPTCHA