Contracted Enrollment Request Practitioner

Please attach ODF that is valid within 1 year from the signature date

Are you registered with CAQH? *
Is this submission affiliated with a Physician Organization? *

Please Select Lines of Business required*
Please enter birth date in this format- MM/DD/YYYY
Gender *
Are you a hospital based only provider not practicing in an office setting? *
Please input in MM/DD/YYYY format.
Applying As required*
Add Provider Race/Ethnicity
Exclude from Directory *
If PCP, are you accepting new patients? *
What gender restrictions do you have? *
What age restrictions do you have? *

Are you board certified? *
Do you offer direct laboratory services? *
Do you have a CLIA Certificate? *
Do you have a CLIA Waiver? *

Provider Directory Required Data Survey

CMS has provided guidance on data elements which will be required for tracking and which will be published in our Provider Directory. These data elements need to be collected at this time and will be required to be updated regularly. This brief questionnaire has been designed to easily collect this information by location.

Practice Location Hours of Operation

Office hours to be entered as (Ex: 8:00am- 5:00pm)
Office hours to be entered as (Ex: 8:00am- 5:00pm)
Office hours to be entered as (Ex: 8:00am- 5:00pm)
Office hours to be entered as (Ex: 8:00am- 5:00pm)
Office hours to be entered as (Ex: 8:00am- 5:00pm)
Office hours to be entered as (Ex: 8:00am- 5:00pm)
Office hours to be entered as (Ex: 8:00am- 5:00pm)

For this practice location, please specify which accessibility options you have for individuals with physical disabilities:

Parking spaces, curb ramps, or loading zones at building entrance *
Doorways wide enough to ensure safe passage by individuals using mobility aids *
Wheelchair accessible restrooms with grab bars and accessible lavatories *
ASL Signage and raised tactile text characters at office, elevator, and restroom doors *
Medical equipment accessible to patients using mobility aids *
Exam rooms accessible to patients using mobility aids *

Is the provider's location on an accessible public transportation route?

Bus *
Rail *
Other Transportation *
Does this location offer non-English languages (including ASL) on-site by qualified healthcare interpreters? *
Which non-English languages are provided on-site by qualified healthcare physicians, office staff and or interpreters at this location? required*
Has the provider completed cultural competence training? *
If the answer is Yes, Please complete the checkboxes below. required*

Does the provider have specialized training and experience in treating the following?

If the answer is Yes, Please complete the checkboxes below.
Does the provider support electronic prescribing? *
Does the provider supply translation services for written materials? *
Is the provider accepting new patients? *
Is the Provider a Minority-owned or controlled agencies and organizations? *
Is this submission involving an FQHC (Federally Qualified Health Center)? *
If you need to enroll more than 5 providers, please fill out the Roster Template and upload here. Additionally, if you are submitting multiple locations for one Practitioner you may submit a roster.
Please enter date in this format: MM/DD/YYYY
Attestation required*

Note: If you have already completed your application with CAQH, please ensure that you have authorized Meridian to access your data. This can be done by calling CAQH at (888) 599-1771 or by logging into your account and adding Meridian to your list of authorized plans. Using the CAQH Universal Credentialing DataSource does not grant participation or constitute applying for participation with Meridian.