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* MM slash DD slash YYYY Contact Name* Contact Title* Contact Phone Number*Contact Email Address* Enter Email Confirm Email Section 1: Provider InformationProvider Name* Include First Name, Middle Initial, and Last NameSpecialty* NPI (Type I)* 10 Digit NumberDegree* Section 2: Practice/Facility InformationPractice/Facility Name* Title Role of Practice Owner (i.e., Director, CEO, etc.)Practice Owner's Full Name NPI (Type II)* 10 Digit NumberTax ID* 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 Office Phone Number*Extension Mailing Address (If different than above) 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 Website URL Start with https://Section 3: Other Provider InformationHas the provider ever been excluded from participating with Medicare/Medicaid*Has the provider ever been excluded from participating with Medicare/Medicaid *YesNoPer 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 *YesNoIf 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? *YesNoN/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. CAPTCHA