MCH | Intake Form

Provider Intake Addition of Individual Provider

INSTRUCTIONS: Please complete this form if a new provider has joined your group and is participating in your group’s Participating Provider Agreement.

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Individual Provider Name:

Title:

Sex:

Male

Female

Date of Birth:

Individual Provider's National Provider Identifier (NPI):

CAQH Number:

New Field:

Medicare Number:

IRS Employer Number:

Are you a Specialty Care Provider?

Yes

No

If yes, please list the specialty:

Other Languages Spoken?

Yes

N

If yes, please list languages:

Provider Group Web Address:

Free Text

Provider Office Information (Payors will use this information for all direct communication)

Office Name:

Start Date at this Location:

Appointment Phone Number:

Address:

City, State, Zip:

Office Fax Number:

Free Text

If Payment Addresss is different, please indicate below:

Payment Address:

Payment City, State, Zip:

Billing Phone Number:

Billing Fax Number:

Correspondence Address is the same as:

Office

Billing

Other (include below)

Correspondence Address:

Correspondence City, State, Zip:

Correspondence Phone Number:

Correspondence Fax Number:

Free Text

Detailed Description of Office Hours; Open & Closed Times (reguired for CMS regulations)

Monday Hours:

Tuesday Hours:

Wednesday Hours:

Thursday Hours:

Friday Hours:

Saturday Hours:

Sunday Hours:

Exclude from Provider Directory?

Ye

No