Provider Roster Form

Please select your primary service type: * Behavioral Health Medical or Physical Health

The below is only applicable for the above service type.

Group Name *

Tax Identification Number *

Group NPI *

Street Address *

City *

State *

Zip Code *

County *

Your Contact Information

Primary Contact Name *

Email *

Phone Number *

Delegated * Yes No

Complete the below roster form if you are submitting enrollment for multiple providers/practitioners. The LOAP/Practitioner Roster requires all columns highlighted in yellow to be completed.

LOAP/Practitioner Roster Form (XLS)

Upload LOAP/Practitioner Roster Form

Please provide any additional information