Please complete this form to ensure accurate provider directory and payment information 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Group Name or Name of Practice and the Fed Tax ID # in the designated fields.
3. Fill in the Hospital Affiliation(s) and Contact Name, followed by the Email Address and number of physicians within your practice.
4. Complete the Service Location(s) section by providing primary and secondary addresses, including suite numbers, city, state, zip code (9 digits), phone, fax, and hours of operation.
5. Indicate if the payment location is the same as billing by checking 'Yes' or 'No'. If 'No', provide the payment address details.
6. In the Provider Information section, fill out each provider's last name, first name, title, type (primary care or specialist), NPI numbers, CAQH #, state license #, alternate languages spoken, race, and ethnicity.
7. Answer questions regarding service capabilities for hearing-impaired patients and physical access accommodations.
8. Finally, check appropriate boxes for Meaningful Use Participation if applicable. Ensure all required documents are attached before submission.

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