Office-Based Provider Enrollment

All fields with an asterisk (*) MUST be completed

Phone

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

Contact Information

Please list your contact information below. By default, all correspondence regarding this application will be conducted through the contact person identified in this section.

Credentialing Contact Info(Required)

Name

Phone

Email(Required)

Practice Contact Info(Required)

Name

Group/Practice Information

Tax ID

Group NPI

Provider Information

Provider Name(Required)

First Middle Last Suffix

Social Security Number(Required)

Date of Birth(Required)

Gender(Required)

Male

Female

Identification Numbers

Individual NPI

CAQH ID

Individual Medicare #

Individual KY Medicaid # (if applicable)

Federal DEA

Number

DEA State

Expiration Date

Licensure Information(Required)

Type

State

License Number

Expiration Date

Provider Start Date(Required)

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

Supervising/Collaborating Physician Name(Required)

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/Collaborating Physician Specialty(Required)

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

Has provider completed cultural competence training?(Required)

Yes

Languages Spoken

Primary Location

Primary address will be listed in directory so long as provider is at location 16 hours or more (unless opted out of directory). Covering locations will not be listed in directory.

Practice Website(Required)

Website may be published in payer directory

Practice Email(Required)

Email may be published in payer directory

Address Type(Required)

Primary Office

Covering Only

Primary Location - Group Name(Required)

Include DBA name if applicable.

Primary Location - Address(Required)

Address Line 1 Address Line 2 City State ZIP Code

Primary Location - Phone/Fax(Required)

Phone

Fax

Directory Opt-Out for this location

Yes

Group NPI for this Address(Required)

FTE Requirement(Required)

Is provider at this site at least 16 hours per week?

Yes

Does provider provide EPSDT services at this site?(Required)

Yes

Does practice provide American Sign Language services at this site?(Required)

Yes

Does this site participate in KHIE?(Required)

Yes

Age Range Seen(Required)

(00-99 or designate other)

Primary Location - Office Hours(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Does practice offer lab services at this site?(Required)

Yes

CLIA Number(Required)

CLIA Expiration Date(Required)

Primary Location - Accessibility/Capability(Required)

Please indicate "Y" = Yes or "N" = No.

Handicap Accessibility

TDD Hearing Capability

Bus Route Accessibility

Is there a Gender Restriction at this Site?

Female Only

Male Only

Is provider a locum tenens provider?(Required)

Yes

Primary Location - Accepting New Patients(Required)

Yes; Provider accepts patient appointments at this location.

No; Provider only provides coverage at this location

Other

Primary Location - PCP or Specialist(Required)

Is provider a PCP or a Specialist at this location?

PCP

Specialist

Other

Scope of Practice for this site:(Required)

Primary Care

Specialty Care

Urgent Care

Walk-In Care

Inpatient Care

Emergency Care

If specialty care, please designate the practice specialty(Required)

Pay-To Address

Use Primary Address for Pay-To Address

Yes

Pay-To Group Name(Required)

Pay-To Address(Required)

Street Address Address Line 2 City State ZIP Code

Pay-To Phone/Fax

Phone

Fax

Correspondence Address

Use Primary Address for Correspondence

Yes

Use Pay-To Address for Correspondence

Yes

Correspondence Address(Required)

Street Address Address Line 2 City State ZIP Code

Correspondence Address Phone/Fax/Email

Phone

Fax

Provider has Alternate Site Location(s)(Required)

Yes

Alternate Site Location 1

Address Type(Required)

Alternate Office

Covering Only

Alternate Site Location 1 - Group Name(Required)

Include DBA name if applicable.

Alternate Site Location 1 - Address(Required)

Address Line 1 Address Line 2 City State ZIP Code

Alternate Site Location 1 - Phone/Fax

Phone

Fax

Directory Opt-Out for this location

Yes

Group NPI for this Address(Required)

Does provider provide EPSDT services at this site?(Required)

Yes

Does practice provide American Sign Language services at this site?(Required)

Yes

Does this site participate in KHIE?(Required)

Yes

FTE Requirement(Required)

Is provider at this site at least 16 hours per week?

Yes

Age Range Seen(Required)

(00-99 or designate other)

Alternate Site Location 1 - Office Hours

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Does practice offer lab services at this site?(Required)

Yes

CLIA Number(Required)

CLIA Expiration Date(Required)

Alternate Site Location 1 - Accessibility/Capability(Required)

Please indicate "Y" = Yes or "N" = No.

Handicap Accessibility

TDD Hearing Capability

Bus Route Accessibility

Is there a Gender Restriction at this Site?

Female Only

Male Only

Is provider a locum tenens provider?(Required)

Yes

Alternate Site Location 1 - Accepting New Patients(Required)

Yes; Provider accepts patient appointments at this location.

No; Provider only provides coverage at this location

Other

Alternate Site Location 1 - PCP or Specialist(Required)

Is provider a PCP or a Specialist at this location?

PCP

Specialist

Other

Scope of Practice for this site:(Required)

Primary Care

Specialty Care

Urgent Care

Walk-In Care

Inpatient Care

Emergency Care

If specialty care, please designate the practice specialty(Required)

Provider has an additional Alternate Site Location(Required)

Yes

Alternate Site Location 2

Address Type(Required)

Alternate Office

Covering Only

Alternate Site Location 2 - Group Name(Required)

Include DBA name if applicable.

Alternate Site Location 2 - Address

Address Line 1 Address Line 2 City State ZIP Code

Alternate Site Location 2 - Phone/Fax

Phone

Fax

Directory Opt-Out for this location

Yes

Group NPI for this Address(Required)

FTE Requirement(Required)

Is provider at this site at least 16 hours per week?

Yes

Does provider provide EPSDT services at this site?(Required)

Yes

Does practice provide American Sign Language services at this site?(Required)

Yes

Does this site participate in KHIE?(Required)

Yes

Age Range Seen(Required)

(00-99 or designate other)

Alternate Site Location 2 - Office Hours

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Does practice offer lab services at this site?(Required)

Yes

CLIA Number(Required)

CLIA Expiration Date(Required)

Alternate Site Location 2 - Accessibility/Capability(Required)

Please indicate "Y" = Yes or "N" = No.

Handicap Accessibility

TDD Hearing Capability

Bus Route Accessibility

Is there a Gender Restriction at this Site?

Female Only

Male Only

Is provider a locum tenens provider?(Required)

Yes

Alternate Site Location 2 - Accepting New Patients(Required)

Yes; Provider accepts patient appointments at this location.

No; Provider only provides coverage at this location

Other

PCP or Specialist

Is provider a PCP or a Specialist at this location?

PCP

Specialist

Other

Scope of Practice for this site:(Required)

Primary Care

Specialty Care

Urgent Care

Walk-In Care

Inpatient Care

Emergency Care

If specialty care, please designate the practice specialty(Required)

Alternate Site Pay-To Address

Alternate Site Pay-To Address same as Primary Pay-To Address

Yes

Alternate Site Pay-To Address - Group Name(Required)

Include DBA name if applicable.

Alternate Site Pay-To Address(Required)

Street Address Address Line 2 City State ZIP Code

Alternate Site Pay-To Address - Phone/Fax

Phone

Fax

Additional Information

Provider bills for DME services(Required)

* If Yes, please attach a DME specific Sample Claim Form.

Yes *

Telehealth Services(Required)

Does the provider offer Telehealth Services?

Yes

Medicare Advantage Participation

Does the Provider wish to Participate in Medicare Advantage via Center Care?(Required)

Yes

Medicare Advantage - Provider Category / Panel Designation

PCP - Open Panel (all locations)

PCP - Closed Panel (all locations)

Specialist - Accepting New Patients (all locations)

Specialist - Not Accepting New Patients (all locations)

PCP - Panel varies between locations

Specialist - Acceptance varies between locations

Panel Maximum Number for Medicare

PCP Designation by location

Location Address

Type (Open/Closed)

Acceptance of New Patients by location

Location Address

Acceptance (Yes/No)

Medicaid Participation

Does the Provider wish to Participate in KY Medicaid Managed Care via Center Care?(Required)

Yes

Kentucky Medicaid ID

Applying for a Medicaid ID

If you have not yet applied for a Medicaid ID, please follow the below link to Kentucky’s Department for Medicaid Services website and follow the instructions for obtaining a Kentucky Medicaid ID Number: https://chfs.ky.gov/agencies/dms/dpi/pe/Pages/apply.aspx

Medicaid - Provider Category and Panel Designation

PCP - Open Panel (all locations)

PCP - Closed Panel (all locations)

Specialist - Accepting New Patients (all locations)

Specialist - Not Accepting New Patients (all locations)

PCP - Panel varies between locations

Specialist - Acceptance varies between locations

Panel Maximum Number for Medicaid

PCP Designation by location

Location Address

Type (Open/Closed)

Acceptance of New Patients by location

Location Address

Acceptance (Yes/No)

Notes

Notes/Comments

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

Supporting Documentation

Click here to access the Center Care Credentialing Requirements.
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(Required)

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)

W-9 Form (all provider types)

Sample Claim form (without PHI)

Center Care Credentialing Requirements Attestation(Required)

Yes, I have reviewed the Center Care Credentialing Requirements and agree to upload the necessary supporting documentation to this submission or to the provider's CAQH application. Furthermore, I understand that if I do not provide Center Care with all necessary supporting documentation as requested, this application may be deemed incomplete potentially resulting in a delay in the provider's effective date for participation.

Upload Files

Please upload the required supporting documentation here, as applicable to the credentialing requirements for this provider type.

Drop files here or

Max. file size: 50 MB.

Sample Claim Form

Please upload a copy of your Sample Claim Form(s) here, specific to each location.

Drop files here or

Max. file size: 50 MB.

Upload Contract

Please upload a copy of your signed contract if you are enrolling a new Tax ID.

Drop files here or

Max. file size: 50 MB.

W-9 Form

Please upload a copy of your signed and dated W-9 form here. Please note, this form must be the current version available from the IRS.

Drop files here or

Max. file size: 50 MB.

DME Specific Sample Claim Form

You indicated that this provider bills for DME services. Please upload a copy of your DME Specific Sample Claim Form(s) here.

Drop files here or

Max. file size: 50 MB.

CLIA Certificate

You indicated that this practice offers lab services. Please upload a copy of your CLIA Certificate as applicable to each location.

Drop files here or

Max. file size: 50 MB.

Documentation from KY Telehealth Network

You indicated that this provider offers telehealth services. Please upload the applicable documentation from the KY Telehealth Network.

Drop files here or

Max. file size: 50 MB.