Provider Enrollment Intake

Welcome! This form is for providers who are already credentialed and need to be enrolled with one or more insurance payers. Enrollment is the process of activating your billing privileges with each payer so you can begin submitting claims and receiving payment.

If you are a new provider who has not yet been credentialed, please reach out to Andrea as you will need to use our Credentialing Intake Form instead.

Before you start, have the following nearby: your CAQH ProView login, NPI confirmation, current malpractice declarations page, W-9, and any existing payer contracts or welcome letters.

This intake has two parts. Complete the provider information form below and hit Submit — you will then be directed to the document upload form. Both submissions are required before your enrollment work can begin.

All information submitted is kept strictly confidential and used solely for enrollment purposes in accordance with our HIPAA privacy practices.