Provider Data Intake Form 2025

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 details including name, email, phone number, and address. Make sure to include city, state, and ZIP code + four digits.
6. List all practice locations (up to five) along with their respective addresses. 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.
8. Review all entries for accuracy before submitting. Once completed, email the form to providerenrollmenttx@amerihealthcaritas.com or fax it to 1-866-935-4807.

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