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- - - Neighborhood has been helping Rhode Island families stay healthy for almost 30 years by providing access to excellent health care.
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Change the Role (PCP or Specialist) of a Current Provider

Please complete the following information to change a participation provider's role (PCP or Specialist) at their affiliated location.
Effective Date*
MM slash DD slash YYYY
Group/Entity NPI*
Group/Entity Name*
Group/Entity TIN*
Provider NPI*
Provider Name*
Primary Specialty*
Secondary Specialty
Emergency/Urgent Care Provider*
Emergency/Urgent Care Provider *
- Yes
- No
Practice Name*
Practice NPI (if applicable)
Practice Address*
Street Address Address Line 2 City State ZIP Code
Practice Phone*
Current role at this location*
Current role at this location *
- PCP
- Specialist
New role at this location*
New role at this location *
- Specialist
New role at this location*
New role at this location *
- PCP
Specialty*
Name of Provider Assuming Panel*
Provider NPI*
Is the provider accepting new patients at this location?*
Is the provider accepting new patients at this location? *
- Yes
- No
Provider's hours at this location*
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
Sunday Hours*
Sunday Hours *
- Custom
- Open 24 Hours
Sunday Open*

: Hours

Minutes

AM/PM
Sunday Close*

: Hours

Minutes

AM/PM
Monday Hours*
Monday Hours *
- Custom
- Open 24 Hours
Monday Open*

: Hours

Minutes

AM/PM
Monday Close*

: Hours

Minutes

AM/PM
Tuesday Hours*
Tuesday Hours *
- Custom
- Open 24 Hours
Tuesday Open*

: Hours

Minutes

AM/PM
Tuesday Close*

: Hours

Minutes

AM/PM
Wednesday Hours*
Wednesday Hours *
- Custom
- Open 24 Hours
Wednesday Open*

: Hours

Minutes

AM/PM
Wednesday Close*

: Hours

Minutes

AM/PM
Thursday Hours*
Thursday Hours *
- Custom
- Open 24 Hours
Thursday Open*

: Hours

Minutes

AM/PM
Thursday Close*

: Hours

Minutes

AM/PM
Friday Hours*
Friday Hours *
- Custom
- Open 24 Hours
Friday Open*

: Hours

Minutes

AM/PM
Friday Close*

: Hours

Minutes

AM/PM
Saturday Hours*
Saturday Hours *
- Custom
- Open 24 Hours
Saturday Open*

: Hours

Minutes

AM/PM
Saturday Close*

: Hours

Minutes

AM/PM
Additional Information Required to Process PCP Role Change Request
Name of Provider assuming panel*
Provider NPI*
Specialty (Must match the provider's PCP role)*
Details for the person submitting the form
Name*
Title*
Phone Number*
Email*
Date*
MM slash DD slash YYYY
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We comply with applicable civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. We also provide language assistance. Read our notice here.

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Please Note

By clicking this link, you will be leaving the Neighborhood Health Plan of Rhode Island website.

Please Read

You are leaving the Neighborhood INTEGRITY (Medicare-Medicaid Plan) website and going to the non-INTEGRITY product website.