Facility and Ancillary Providers

This form is only to be used if the Tax ID is NOT currently contracted with Center Care. If your Tax ID is not yet contracted, please proceed with completing the below.
All fields with an asterisk (*) MUST be completed

Upon submission of this form, we will review and be in touch with you regarding next steps.

Contact Information
Please list your contact information below. By default, all correspondence will be conducted through the individual identified in this section.
First Name Last Name Phone #
Email*
Facility or Ancillary Provider Information
**If you do not bill as a facility but at the professional level, do not complete this form. You will need to go back and select the “Individual Provider” form to complete.**
Practice Name*
Practice Address*
Street Address Address Line 2 City State ZIP Code
County*
Practice Phone*
Please provide a description of services provided
Are there other locations?*
- Yes
- No

Please list the county & state of the additional location(s)*

County	State

Affiliations (if applicable)

(i.e. PHO/IPA/Healthcare System)

Are you interested in participating with KY Medicaid Managed Care via Center Care?*
- Yes
- No
Do you have or have you already applied for a Kentucky Medicaid Number?*
- Yes
- No
Please enter your Kentucky Medicaid Number below*
Are you interested in participating with Medicare Advantage products via Center Care?*
- Yes
- No
Identification Numbers
Tax ID Number (TIN)*
Facility or Ancillary NPI Number*
Medicare Number
CAQH ID Number
Comments
Please list any additional information that might assist us in reviewing your application.
Name
This field is for validation purposes and should be left unchanged.

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Contact Information

Facility or Ancillary Provider Information

Identification Numbers