The CFI Provider Enrollment Application - New Hampshire Healthy 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Legal Information' section. Enter your legal name, tax ID, Medicaid number, state license number, National Provider ID (NPI), and Medicare number accurately.
3. Proceed to the 'Primary Facility Information' section. Input your location name (Doing Business As), telephone number, primary contact name, email address, and complete the address fields including city, state, zip code, and county.
4. In the 'Service Hours' section, indicate your operating hours for each day of the week. Confirm if services are provided at least five days a week and specify if PAs, CNMs, or Nurse Practitioners are utilized.
5. Fill out the 'Billing Information' section with details on where payments should be sent. Include billing contact information such as phone number and email.
6. Select all applicable counties serviced and services offered from the provided options to ensure comprehensive coverage of your offerings.

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