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Non-Contracted Provider Set-Up

Provider/Facility Information

*1 GNPI per request
*not applicable for Commercial Programs
*i.e. Clinic, Hospital, DME, RHC, FQHC, Ambulance, etc.

Document Attachments Required

Provider/Facility Information

*1 GNPI per request
*not applicable for Commercial Programs
*i.e. Clinic, Hospital, DME, RHC, FQHC, Ambulance, Group Practice, etc.

Practitioner Information

*not applicable for Commercial Programs

Document Attachments Required

Last Updated: 06/09/2021