Office-Based Provider EnrollmentAll fields with an asterisk (*) MUST be completed X/TwitterThis field is for validation purposes and should be left unchanged.Contact InformationPlease 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*NamePhoneEmail* Practice Contact Info*NameEmailGroup/Practice InformationTax IDGroup NPIProvider InformationProvider Name* First Middle Last Suffix Social Security Number*Date of Birth*MMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Identification NumbersIndividual NPICAQH IDIndividual Medicare #Individual KY Medicaid # (if applicable)Federal DEANumberDEA StateExpiration Date Licensure Information*TypeStateLicense NumberExpiration Date Provider Start Date*MMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Degree/SpecialtyPlease list provider's Degree (e.g. MD, APRN, etc.), Primary Specialty (e.g. Internal Medicine, Pediatrics, etc.), and Secondary Specialty (if applicable).DegreePrimary SpecialtySecondary Specialty TaxonomyPlease list provider's Primary and Secondary Taxonomy. The Secondary Taxonomy is only required if there is a Secondary Specialty listed above.Primary TaxonomySecondary Taxonomy Supervising/Collaborating 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/Collaborating Physician Specialty*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?* Yes No Languages SpokenPrimary LocationPrimary 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*Website may be published in payer directoryPractice Email*Email may be published in payer directoryAddress Type* Primary Office Covering Only Primary Location - Group Name*Include DBA name if applicable.Primary Location - Address* Address Line 1 Address Line 2 City 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 State ZIP Code Primary Location - Phone/Fax*PhoneFaxDirectory Opt-Out for this location Yes Group NPI for this Address*FTE Requirement*Is provider at this site at least 16 hours per week? Yes No Does provider provide EPSDT services at this site?* Yes No Does practice provide American Sign Language services at this site?* Yes No Does this site participate in KHIE?* Yes No Age Range Seen*(00-99 or designate other)Primary Location - Office Hours*MondayTuesdayWednesdayThursdayFridaySaturdaySundayDoes practice offer lab services at this site?* Yes No CLIA Number*CLIA Expiration Date* Month Day Year Primary Location - Accessibility/Capability*Please indicate "Y" = Yes or "N" = No.Handicap AccessibilityTDD Hearing CapabilityBus Route AccessibilityIs there a Gender Restriction at this Site? Female Only Male Only No Is provider a locum tenens provider?* Yes No Primary Location - Accepting New Patients* Yes; Provider accepts patient appointments at this location. No; Provider only provides coverage at this location Primary Location - PCP or Specialist*Is provider a PCP or a Specialist at this location? PCP Specialist Scope of Practice for this site:* Primary Care Specialty Care Urgent Care Walk-In Care Inpatient Care Emergency Care If specialty care, please designate the practice specialty*Pay-To AddressUse Primary Address for Pay-To Address Yes No Pay-To Group Name*Pay-To Address* Street Address Address Line 2 City 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 State ZIP Code Pay-To Phone/FaxPhoneFaxCorrespondence Address Use Primary Address for Correspondence Yes No Use Pay-To Address for Correspondence Yes No Correspondence Address* Street Address Address Line 2 City 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 State ZIP Code Correspondence Address Phone/Fax/EmailPhoneFaxEmail Provider has Alternate Site Location(s)* Yes No Alternate Site Location 1Address Type* Alternate Office Covering Only Alternate Site Location 1 - Group Name*Include DBA name if applicable.Alternate Site Location 1 - Address* Address Line 1 Address Line 2 City 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 State ZIP Code Alternate Site Location 1 - Phone/FaxPhoneFaxDirectory Opt-Out for this location Yes Group NPI for this Address*Does provider provide EPSDT services at this site?* Yes No Does practice provide American Sign Language services at this site?* Yes No Does this site participate in KHIE?* Yes No FTE Requirement*Is provider at this site at least 16 hours per week? Yes No Age Range Seen*(00-99 or designate other)Alternate Site Location 1 - Office HoursMondayTuesdayWednesdayThursdayFridaySaturdaySundayDoes practice offer lab services at this site?* Yes No CLIA Number*CLIA Expiration Date* Month Day Year Alternate Site Location 1 - Accessibility/Capability*Please indicate "Y" = Yes or "N" = No.Handicap AccessibilityTDD Hearing CapabilityBus Route AccessibilityIs there a Gender Restriction at this Site? Female Only Male Only No Is provider a locum tenens provider?* Yes No Alternate Site Location 1 - Accepting New Patients* Yes; Provider accepts patient appointments at this location. No; Provider only provides coverage at this location Alternate Site Location 1 - PCP or Specialist*Is provider a PCP or a Specialist at this location? PCP Specialist Scope of Practice for this site:* Primary Care Specialty Care Urgent Care Walk-In Care Inpatient Care Emergency Care If specialty care, please designate the practice specialty*Provider has an additional Alternate Site Location* Yes No Alternate Site Location 2Address Type* Alternate Office Covering Only Alternate Site Location 2 - Group Name*Include DBA name if applicable.Alternate Site Location 2 - Address Address Line 1 Address Line 2 City 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 State ZIP Code Alternate Site Location 2 - Phone/FaxPhoneFaxDirectory Opt-Out for this location Yes Group NPI for this Address*FTE Requirement*Is provider at this site at least 16 hours per week? Yes No Does provider provide EPSDT services at this site?* Yes No Does practice provide American Sign Language services at this site?* Yes No Does this site participate in KHIE?* Yes No Age Range Seen*(00-99 or designate other)Alternate Site Location 2 - Office HoursMondayTuesdayWednesdayThursdayFridaySaturdaySundayDoes practice offer lab services at this site?* Yes No CLIA Number*CLIA Expiration Date* Month Day Year Alternate Site Location 2 - Accessibility/Capability*Please indicate "Y" = Yes or "N" = No.Handicap AccessibilityTDD Hearing CapabilityBus Route AccessibilityIs there a Gender Restriction at this Site? Female Only Male Only No Is provider a locum tenens provider?* Yes No Alternate Site Location 2 - Accepting New Patients* Yes; Provider accepts patient appointments at this location. No; Provider only provides coverage at this location PCP or SpecialistIs provider a PCP or a Specialist at this location? PCP Specialist Scope of Practice for this site:* Primary Care Specialty Care Urgent Care Walk-In Care Inpatient Care Emergency Care If specialty care, please designate the practice specialty*Alternate Site Pay-To AddressAlternate Site Pay-To Address same as Primary Pay-To Address Yes No Alternate Site Pay-To Address - Group Name*Include DBA name if applicable.Alternate Site Pay-To Address* Street Address Address Line 2 City 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 State ZIP Code Alternate Site Pay-To Address - Phone/FaxPhoneFaxAdditional InformationProvider bills for DME services** If Yes, please attach a DME specific Sample Claim Form. Yes * No Telehealth Services*Does the provider offer Telehealth Services? Yes No Medicare Advantage ParticipationDoes the Provider wish to Participate in Medicare Advantage via Center Care?* Yes No 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 MedicarePCP Designation by locationLocation AddressType (Open/Closed) Acceptance of New Patients by locationLocation AddressAcceptance (Yes/No) Medicaid ParticipationDoes the Provider wish to Participate in KY Medicaid Managed Care via Center Care?* Yes No Kentucky Medicaid IDApplying for a Medicaid IDIf 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 MedicaidPCP Designation by locationLocation AddressType (Open/Closed) Acceptance of New Patients by locationLocation AddressAcceptance (Yes/No) NotesNotes/CommentsPlease provide any comments that may assist in processing this enrollment request.Supporting DocumentationClick 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*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* 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 FilesPlease upload the required supporting documentation here, as applicable to the credentialing requirements for this provider type. Drop files here or Select files Max. file size: 50 MB. Sample Claim FormPlease upload a copy of your Sample Claim Form(s) here, specific to each location. Drop files here or Select files Max. file size: 50 MB. Upload ContractPlease upload a copy of your signed contract if you are enrolling a new Tax ID. Drop files here or Select files Max. file size: 50 MB. W-9 FormPlease 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 Select files Max. file size: 50 MB. DME Specific Sample Claim FormYou 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 Select files Max. file size: 50 MB. CLIA CertificateYou indicated that this practice offers lab services. Please upload a copy of your CLIA Certificate as applicable to each location. Drop files here or Select files Max. file size: 50 MB. Documentation from KY Telehealth NetworkYou indicated that this provider offers telehealth services. Please upload the applicable documentation from the KY Telehealth Network. Drop files here or Select files Max. file size: 50 MB.
