Provider Data Intake Form 2026

1. Click ‘Get Form’ to open the Provider Data Intake Form in the editor.
2. Begin by selecting your provider type: Primary care provider (PCP), Specialist, or Behavioral health. This helps categorize your practice.
3. Fill in the Entity name as it appears on your W9, and include the Independent practice association (IPA) name if applicable.
4. Provide your Name doing business as (if applicable) and enter your Provider TIN/EIN number, ensuring it is nine characters long.
5. Complete the Primary contact information including name, email, phone number, and address details such as street address, city, state, and ZIP code.
6. List all practice locations and their corresponding details. If you need more space, feel free to attach an additional document.
7. For the practitioner roster section, input each practitioner's first name, last name, degree, specialty, CAQH registration number, taxonomy code, Medicaid ID and NPI as required.

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