CONTRACT DEMOGRAPHIC FORM

Basic Information
Legal Entity (as shown on W9):

DBA Name:
Individual NPI:
Federal Tax ID:
Group NPI:
Specialty: PCP: Yes No
Type: Individual Group Ancillary (Facility/Clinic/Stand Alone)
Website:
Service Address (If more than one, please provide roster of locations)
Street Address:

Apt/Suite/Other: City: County:

State: Zip: Email:
Phone: Ext: Fax:
Address of Notice
Street Address:
Apt/Suite/Other: City:

State: Zip: Email:

Phone: Ext: Fax:
Contract Contact Person
First Name: Last Name:
Street Address:

Apt/Suite/Other: City:
State: Zip: Email:

Phone: Ext: Fax:

Contract Signee/Email:
Credentialing Contact Person (if different from Contract Contact)
First Name: Last Name:

Phone: Ext.: Email:

Please select desired plans: Please forward the following current items:

Commercial PPO/POS/EPO W9
Medicare PPO Proof of Malpractice
Medicare PFFS Insurance Credentialing App
Medicare HMO (Facilities) CAQH (Physicians)
Physician and/or Group Roster