Provider Interest Form - UMBH - University of Miami - umbh med miami 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Provider Information' section. Enter your name, date, primary address, Tax ID#, individual NPI#, group NPI#, and group name. Ensure all fields are completed accurately.
3. Indicate your contact details by providing your email and telephone number. This information is crucial for communication regarding your application.
4. Select the languages you speak from the provided options. This helps in understanding your capabilities better.
5. Review the minimum requirements for network consideration and check the boxes confirming your eligibility as an independently licensed clinician.
6. Choose your provider type/description by checking one of the options listed, such as MD/DO or LCSW.
7. Identify the clinical populations you serve and treatment modalities you offer by checking all applicable boxes.
8. Finally, select up to eight specialty areas where you would like to be considered. Make sure to review this section carefully before submission.
9. Once completed, fax the form to 305-243-6886 attn: Provider Relations Department as instructed at the bottom of the form.

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