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 Group/Entity NPI* Group/Entity Name* Group/Entity TIN* Provider NPI* Provider Name* Primary Specialty* Secondary Specialty Practice Name* Practice NPI (if applicable) Practice Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Practice Phone*Emergency/Urgent Care Provider*Emergency/Urgent Care Provider *YesNoPhysician Assistant Provider*Physician Assistant Provider *Yes (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)NoPA Questionnaire*Accepted file types: pdf, Max. file size: 200 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: 200 MB. Is the provider accepting new patients at this location?*Is the provider accepting new patients at this location? *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: 200 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