1. Name of person completing this form:
2. Provider Name (Practice Location Only):
3. Address:
4. City, State Zip:
5. E-mail Address for Person Completing this Form
6. County:
7. Practice Telephone: (ex. 888-343-3547)
8. Languages Spoken:
9. Primary Specialty:
10. Secondary Specialty:
11. Other locations:
12. Does the provider/group/facility render services in the member's home?
12b. List all services rendered in the home:
13. Provider's Tax Identification Number:
14. Group Tax Identification Number (if applicable):
15. Legal Entity Name
16. How many providers are in the group? (if applicable)
Please list the first five:
17. Group NPI #:
18. Is this Provider part of existing par-credentialed group?
19. Hospital Affiliations:
20. Board Certified:
21. As Fidelis Care has moved to a paperless environment, all providers are expected to submit and accept communications electronically. Are you willing and able to:
Submit claims electronically?
Accept electronic communications such as remittance advice (EOB) or member rosters?
22. How did you hear about Fidelis Care?
23. If you are a PCP, please advise us who you refer members to for specialty care:
If you are a Behavioral Health Provider, please complete questions 1-21 and someone will contact you regarding additional questions to be completed.
*Note: Minimum Provider Qualifications: Valid, current license; valid current DEA certificate; completion of residency training; graduation from Medical/Professional school; certification; and hospital affiliation.
**Note: Pathologist, Radiologist, Anesthesiologists, Neonatologists, Emergency Medicine Physicians, Hospitalists, and Behavioral Health practitioners who practice exclusively within a State licensed facility (OMH or Article 28) do not have to be individually credentialed. Practitioners within these specialities who provide services independently of these facilities shall be individually credentialed.