Hospital-Based Provider EnrollmentAll fields with an asterisk (*) MUST be completed Contact InformationPlease list your contact information here. By default all correspondence will be communicated through the individual identified in this section.*First NameLast NameTitlePhone # Email* Provider InformationProvider Name* First Middle Last Suffix Social Security Number*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Identification NumbersIndividual NPIIndividual Medicare #Individual KY Medicaid # (if applicable)Federal DEANumberDEA StateExpiration DateLicensure Information*TypeStateLicense NumberExpiration DateDegree/Specialty*Please list provider's degree (e.g. MD. APRN, etc.), Primary Specialty (e.g. Internal Medicine, Pediatrics, etc.), and Secondary Specialty (if applicable).DegreePrimary SpecialtySecondary SpecialtyTaxonomy*Please list provider's Primary and Secondary Taxonomy. The Secondary Taxonomy is only required if there is a Secondary Specialty listed above.Primary TaxonomySecondary TaxonomyAdditional InformationLiability Insurance Information*CarrierLimitsPolicy NumberExpiration DateBoard Certification Information*Indicate the provider's specialty/sub-specialty field(s) of practice and respective board certification:SpecialtyBoard Certified (Y/N)Sub-specialtyBoard 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 MM slash DD slash YYYY Primary Location - Tax ID / Group NPITINGroup NPIPrimary Location - Practice Name*Primary Location - Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Location - County*Primary Location - Phone/FaxPhoneFaxAre 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 directoryPractice Email*Email may be published in payer directoryPay-To AddressUse Primary Address Information for Pay-To Address* Yes No Pay-To Name*Pay-To Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Pay-To Phone/FaxPhoneFaxProvider has Alternate Site Location(s)* Yes No Alternate Site Location 1Alternate Site Location 1 - Practice Name*Alternate Site Location 1 - Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Alternate Site Location 1 - Phone/FaxPhoneFaxAre 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 2If provider does not have a second alternate location, skip to next section.Alternate Site Location 2- Practice NameAlternate Site Location 2 - Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Alternate Site Location 2 - Phone/FaxPhoneFaxAre 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 PrivilegesHospital Privileges*List all hospitals where you currently provide hospital-based services, beginning with the Primary.HospitalCityStatePrivilegesDepartmentEducation and TrainingEducation 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 CompletionSchool NameSchool Mailing AddressInternship/Residency*Month/Year CompletionOrganizationOrganization Mailing AddressFellowship TrainingMonth/Year CompletionOrganizationOrganization Mailing AddressUpload 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 SpokenNotesNotes/CommentsPlease provide any comments that may assist in processing this enrollment request.Supporting DocumentationFailure 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 FilesPlease upload the required supporting documentation here, as applicable to the provider. Drop files here or Select files Max. file size: 50 MB. CommentsThis field is for validation purposes and should be left unchanged.
