Provider Application – Facility Type

Instructions:

Please complete the below application and provide comments as appropriate.

All information is confidential.

Required fields are marked with an asterisk (*)

The information entered on this page can be saved to allow for completion at a later date. Incomplete requests will automatically delete from the system after 30 days of inactivity.

Date*

Contact Name*

Contact Title*

Contact Phone Number*

Contact Email Address*

Enter Email Confirm Email

Section 1: Provider Information

Provider Name*

Include First Name, Middle Initial, and Last Name

Specialty*

NPI (Type I)*

10 Digit Number

Degree*

Section 2: Practice/Facility Information

Practice/Facility Name*

Title Role of Practice Owner

(i.e., Director, CEO, etc.)

Practice Owner's Full Name

NPI (Type II)*

10 Digit Number

Tax ID*

Address*

Street Address Address Line 2 City State ZIP

Office Phone Number*

Extension

Mailing Address (If different than above)

Street Address Address Line 2 City State ZIP

Website URL

Start with https://

Section 3: Other Provider Information

Has the provider ever been excluded from participating with Medicare/Medicaid*

Has the provider ever been excluded from participating with Medicare/Medicaid *

Yes
No

Per regulatory requirements any provider who is excluded from participation with Medicaid and/or Medicare is unable to join the network. We encourage you to apply in the future should circumstances change.

Facility and its practitioners are enrolled with Rhode Island Medicaid*

Facility and its practitioners are enrolled with Rhode Island Medicaid *

Yes
No

If you are an Assisted Living Facility or Adult Day Care Provider are you currently certified to provide Home and Community Based Services?*

If you are an Assisted Living Facility or Adult Day Care Provider are you currently certified to provide Home and Community Based Services? *

Yes
No
N/A

Per regulatory requirement all Assisted Living Facilities & Adult Day Care Providers participating in the Neighborhood network are required to provide Home and Community Based Services. Based upon your response these services are not provided at your facility. We welcome you to complete the application should the circumstances change.

If you have any questions please address them in the below section.

Please Attach A Current W-9. W-9 Must have been completed within 6 months of today’s date.*

Accepted file types: pdf, Max. file size: 10 MB.

Submission of this form does not guarantee participation in the Neighborhood Health Plan of Rhode Island network.

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