Provider Application – Other Provider Types

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.

Provider group and its practitioners are enrolled with Rhode Island Medicaid*

Provider group and its practitioners are enrolled with Rhode Island Medicaid *

Yes
No

Per federal requirements, all providers participating in the Neighborhood network are required to be enrolled with Rhode Island Medicaid. Based on the information you have provided you are unable to proceed with your application.

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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