Hospital-Based Provider Enrollment

Company

This field is for validation purposes and should be left unchanged.

Contact Information

Please list your contact information here. By default all correspondence will be communicated through the individual identified in this section.

First Name	Last Name	Title	Phone #

Email*

Provider Information

Provider Name*

First Middle Last Suffix

Social Security Number*

Date of Birth*

Gender*

Male
Female

Identification Numbers

Individual NPI	Individual Medicare #	Individual KY Medicaid # (if applicable)

Federal DEA

Number	DEA State	Expiration Date

Licensure Information*

Type	State	License Number	Expiration Date

Degree/Specialty*

Please list provider's degree (e.g. MD. APRN, etc.), Primary Specialty (e.g. Internal Medicine, Pediatrics, etc.), and Secondary Specialty (if applicable).

Degree	Primary Specialty	Secondary Specialty

Taxonomy*

Please list provider's Primary and Secondary Taxonomy. The Secondary Taxonomy is only required if there is a Secondary Specialty listed above.

Primary Taxonomy	Secondary Taxonomy

Additional Information

Liability Insurance Information*

Carrier	Limits	Policy Number	Expiration Date

Board Certification Information*

Indicate the provider's specialty/sub-specialty field(s) of practice and respective board certification:

Specialty	Board Certified (Y/N)	Sub-specialty	Board Certified (Y/N)

Scope of Practice*

Anesthesiology
Emergency Medicine
Hospitalist
Neonatology
Pathology
Radiology
Other

Locum Tenens provider?

Yes
No

Supervising Physician Name*

If provider is a Nurse Practitioner or Physician Assistant, please list the name of provider's Supervising Physician. If provider is neither, please type N/A.

Supervising Physician Specialty*

If provider is a Nurse Practitioner or Physician Assistant, please list the specialty of the Supervising Physician named above. If provider is neither, please type N/A.

Age Range Seen*

(00-99 or designate other)

Primary Location*

*Please ensure location(s) are that of Center Care par hospitals.

Provider Start Date

Primary Location - Tax ID / Group NPI*

TIN	Group NPI

Primary Location - Practice Name*

Primary Location - Address*

Street Address Address Line 2 City State ZIP Code

Primary Location - County*

Primary Location - Phone/Fax

Phone	Fax

Are American Sign Language services provided at this site?*

Yes
No

Does provider provide EPSDT services at this site?*

Yes
No

Are Telemedicine services provided at this site?*

Yes
No

Does this site participate in KHIE?*

Yes
No

Practice Website*

Website may be published in payer directory

Practice Email*

Email may be published in payer directory

Pay-To Address

Use Primary Address Information for Pay-To Address*

Yes
No

Pay-To Name*

Pay-To Address*

Street Address Address Line 2 City State ZIP Code

Pay-To Phone/Fax

Phone	Fax

Provider has Alternate Site Location(s)*

Yes
No

Alternate Site Location 1

Alternate Site Location 1 - Practice Name*

Alternate Site Location 1 - Address*

Street Address Address Line 2 City State ZIP Code

Alternate Site Location 1 - Phone/Fax

Phone	Fax

Are American Sign Language services provided at this site?*

Yes
No

Does provider provide EPSDT services at this site?*

Yes
No

Are Telemedicine services provided at this site?*

Yes
No

Does this site participate in KHIE?*

Yes
No

Alternate Site Location 2

If provider does not have a second alternate location, skip to next section.

Alternate Site Location 2- Practice Name

Alternate Site Location 2 - Address

Street Address Address Line 2 City State ZIP Code

Alternate Site Location 2 - Phone/Fax

Phone	Fax

Are American Sign Language services provided at this site?*

Yes
No

Does provider provide EPSDT services at this site?*

Yes
No

Are Telemedicine services provided at this site?*

Yes
No

Does this site participate in KHIE?*

Yes
No

Hospital Privileges

Hospital Privileges*

List all hospitals where you currently provide hospital-based services, beginning with the Primary.

Hospital	City	State	Privileges	Department

Education and Training

Education and training information available via*

Please complete the fields provided. If there is not enough space, please attach a CV or Work History.

Direct form entry
CV or Work History Attached

Highest Degree Obtained*

Medical School*

Month/Year Completion	School Name	School Mailing Address

Internship/Residency*

Month/Year Completion	Organization	Organization Mailing Address

Fellowship Training

Month/Year Completion	Organization	Organization Mailing Address

Upload CV / Work History*

Accepted file types: doc, docx, pdf, txt, rtf, Max. file size: 50 MB.

Has provider completed cultural competence training?*

Yes
No

Is provider certified in trauma-informed care (TIC)?*

Yes
No

Has provider been trained in evidence-based practice?*

Yes
No

Languages Spoken

Notes

Notes/Comments

Please provide any comments that may assist in processing this enrollment request.

Supporting Documentation

Failure to submit the necessary documentation may result in the provider's application being deemed incomplete, requiring resubmission of the provider's application. This may also result in a delay of the provider's effective date for participation.

Required Supporting Documentation*

Please ensure all required supporting documentation is submitted as follows. Please use the below as a checklist for this information.

State License (all provider types)
Federal and State DEA Certificates (as applicable)
Certificate of Malpractice Insurance Coverage (all provider types)
Collaborative Agreement for the Prescriptive Authority for Controlled (& Non-Controlled) Substances (APRNs only)
W-9 Form (all provider types)
Sample Claim form (without PHI)

Upload Files

Please upload the required supporting documentation here, as applicable to the provider.

Drop files here or

Max. file size: 50 MB.