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Become a Participating Provider

join our network - participating provider - table content

Practitioner Specialty


  • Clinical Psychologist [PhD; PsyD]
  • Licensed Behavioral Analyst [ABA]
  • Licensed Clinical Social Worker [LCSW]
  • Licensed Marriage & Family Therapist [LMFT]
  • Licensed Mental Health Counselor [LMHC]
  • MD/DO - Psychiatry only (all other MD/DO specialties, see below)
  • Nurse Practitioner, Psychiatry [PMHNP]

Application for Practitioner Enrollment-C Open a PDF

See credentialing requirements for all specialties

Purpose


  • Changing Group Name
  • Changing/adding Tax ID
  • Enrolling a new practitioner who requires credentialing

Practitioner Specialty


  • Anesthesiologist
  • Certified Diabetic Educator (affiliated with Physician Group or Hospital)
  • Certified Registered Nurse Anesthetists [CRNA]
  • Emergency Room
  • Hospitalist
  • Locum Tenens
  • Pathologist
  • Registered Dietician (affiliated with Physician Group or Hospital)

Application for Practitioner Enrollment Open a PDF

See credentialing requirements for all specialties

Purpose


  • Changing/adding Tax ID
  • Enrolling a new practitioner who requires credentialing

Practitioner Specialty


  • Acupuncturist [LAC]
  • Audiologist [AuD]
  • Certified Diabetic Educator [CDE] (Independent)
  • Certified Nurse Midwife [CNM]
  • Certified Nurse Midwife – Home Birth [CNM]
  • Doctor of Chiropractic [DC]
  • Doctor of Optometry [OD]
  • Doctor of Podiatry [DPM]
  • Enterostomal Therapy
  • Medical Doctor [MD/MBBS/BMED]
  • Nurse Practitioner, Primary Care [NP]
  • Occupational Therapist [OT]
  • Oral Maxillofacial Surgery [DMD]
  • Osteopathic Doctor [DO]
  • Physical Therapist [PT]
  • Registered Dietician [RD] (Independent)
  • Speech Pathologist [SLP]

Application for Practitioner Enrollment Open a PDF

See credentialing requirements for all specialties

Purpose


  • Changing Group Name
  • Changing/adding Tax ID
  • Enrolling a new practitioner who requires credentialing

Practitioner Specialty


  • Certified Behavior Analyst Assistant
  • Nurse Practitioner
  • Physician Assistant
  • Registered Nurse First Assistant

Application for Non-Physician Health Care Practitioner Open a PDF

Purpose


  • Already enrolled and updating demographic information, i.e. Supervising Physician, Tax ID, address, etc.
  • Enrolling a new practitioner working under the supervision of a physician.

Practitioner Specialty


  • Endodontist
  • General
  • Oral Maxillofacial Surgery
  • Orthodontist
  • Pediatric Dentist
  • Periodontist
  • Prosthodontist

Application for Dental Enrollment Open a PDF

Purpose


  • Enrolling a new practitioner

Practitioner Specialty


  • Health Coach for Medicare Diabetes Prevention Program

Application for Health CoachOpen a PDF

Purpose


  • Add or update a health coach for an existing MDPP Supplier

Practitioner Specialty


  • Practitioner Name
  • Address, telephone/fax number, ie. Primary Office, Billing, Correspondence, Remittance
  • Terminate a practitioner1

Practitioner Demographic Changes

Purpose


  • Already enrolled and have changes to your practice

1Terminating a Licensed Physician: Any nurse practitioner (NP), physician assistant (PA), or certified behavior analyst assistant that has a collaborating relationship with the terminated licensed physician must complete an Application for Non-Physician Health Care Practitioner to be reassigned.