Contracted Enrollment Request Practitioner

Sample Blank W-9 (PDF)

Complete W-9, at least one in all practitioners share same tax ID *

ODF File (PDF)

Completed and signed Disclosure of Ownership And Control Interest Statement * Please attach ODF that is valid within 1 year from the signature date

Are you registered with CAQH? *

Yes No

If Yes, CAQH Provider ID *

Individual NPI *

Is this submission affiliated with a Physician Organization? *

Yes No

Physician Organization Name(s) *

Please Select Lines of Business *

Medicaid Medicare Ambetter MI Health Link

Provider First Name *

Provider Middle Name

Provider Last Name *

Date of Birth * Please enter birth date in this format- MM/DD/YYYY

Gender *

Male Female

Social Security *

Provider Type (MD, DO, PhD, LCSE, LPC, etc) *

Are you a hospital based only provider not practicing in an office setting? *

Yes No

State License Number *

Issuing State License *

State License Expiration Date * Please input in MM/DD/YYYY format.

Tax ID *

Group Billing NPI *

Practice Name *

Email Address *

Primary Office Street Address *

Suite Number

City *

State *

County *

Zip *

Primary Telephone *

Primary Fax

Office Website

Credentialing Contact Information *

Applying As *

Specialist Primary Care Physician

Specialty *

Add Provider Race/Ethnicity

American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White

Exclude from Directory *

Yes No

If PCP, are you accepting new patients? *

Yes No Yes, existing patients only

What gender restrictions do you have? *

No Restrictions Female Only Male Only

What age restrictions do you have? *

No Restrictions Minimum Age Maximum Age

Lowest Age *

Highest Age *

Are you board certified? *

Yes No

If yes, Board Name *

Exp. Date *

Please list any medical related organizations you have ownership with, e.g., laboratory, home health agency radiology facility, mobile Testing, MRI, etc.: *

Do you offer direct laboratory services? *

Yes No

Do you have a CLIA Certificate? *

Yes No

Do you have a CLIA Waiver? *

Yes No

CLIA Certificate Upload *

Type of Service Provided *

Certificate Number *

Certificate Expiration Date *

CLIA Name *

Tax ID *

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

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

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

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

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

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

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

Sunday * 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 *

Yes No

Doorways wide enough to ensure safe passage by individuals using mobility aids *

Yes No

Wheelchair accessible restrooms with grab bars and accessible lavatories *

Yes No

ASL Signage and raised tactile text characters at office, elevator, and restroom doors *

Yes No

Medical equipment accessible to patients using mobility aids *

Yes No

Exam rooms accessible to patients using mobility aids *

Yes No

Other Accessibility

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

Bus *

Yes No

Rail *

Yes No

Other Transportation *

Yes No

Does this location offer non-English languages (including ASL) on-site by qualified healthcare interpreters? *

Yes No

Has the provider completed cultural competence training? *

Yes No

If the answer is Yes, Please complete the checkboxes below. *

African American Alaskan Native American Indian Asian Hispanic/Latino Pacific Islander Other

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

Does the provider support electronic prescribing? *

Yes No

Does the provider supply translation services for written materials? *

Yes No

Is the provider accepting new patients? *

Yes No

Is the Provider a Minority-owned or controlled agencies and organizations? *

Yes No

Is this submission involving an FQHC (Federally Qualified Health Center)? *

Yes No

Blank Provider Roster (Excel)

Upload Physician Roster 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.

Number of Practitioners being submitted on the roster

Additional Details

Effective Date * Please enter date in this format: MM/DD/YYYY

Attestation *

I hereby certify the above information to be true and correct to the best of my knowledge.

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.