Fillable Adding A-practitioner Form

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Adding A-practitioner Form

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The Adding A-practitioner Form form is 2 pages long and contains:

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  • 31 check-boxes
  • 38 other fields

Country of origin: OTHERS
File type: PDF

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Does the practitioner see members in an office setting? q Yes q No
Practitioner’s primary county location: ______________________________________________________________________
Please check one:
q Practitioner is a PCP
q Practitioner is a Specialist
Please add _________________________________, _____________________________ Effective _____________________
NAME TITLE DATE
Practitioner NPI # _________________________ Practitioner Taxonomy Code __________________________________
Practitioner Medicare # _________________ Practitioner Gender:
q M q F
Practitioner SSN # ____________________________________ Practitioner DOB __________________________________
Practitioner’s Specialty ___________________________________________________________________________________
Practitioner CAQH # ___________________________ Practitioner Office Hours __________________________________
Please check one:
q Practitioner has an active KY Medicaid ID. The Medicaid ID is ______________________________________________
q Practitioner has applied for a KY Medicaid ID. Medicaid ID is pending.
q Please assist in obtaining Practitioner’s Medicaid ID. MAP 811 is included.
Practice Name __________________________________________________________________________________________
Practice NPI __________________________________ Practice Taxonomy Code __________________________________
Passport Health Plan Group ID ____________________________________________________________________________
If this is a new solo set up or a new group set up a “Practice Demographic Form” is required to process this
practitioner add request.
Please check one:
q Practitioner practices only at primary address
q Practitioner practices at all addresses
q Other (List is attached with practice addresses specified)
Please check one:
q Group has an active KY Medicaid ID. The Medicaid ID is ___________________________________________________
q Group has applied for a KY Medicaid ID. Medicaid ID is pending.
q Please assist in obtaining Group’s Medicaid ID. MAP 811 is included.
ADDING A PRACTITIONER FORM
© 2014 PASSPORT HEALTH PLAN (PROV40464)
Tax ID ____________________ Tax Name _____________________________________
Tax Address _______________________________ Tax City ______________________________
Tax State _______ Tax Zip Code _______________ Tax Phone ___________________________
PANEL INFORMATION (IF APPLICABLE)
Age Limitations:
q MIN q MAX
Gender Limitations:
q Male Only q Female Only
Group Panel Status:
q OPEN q CLOSED
VOLUNTARY QUESTIONAIRE
Practitioner Ethnicity: q Non-Hispanic q Hispanic q Unknown
Practitioner Race:
q Black or African American q American Indian/Alaska Native q White
q Native Hawaiian/Other Pacific Islander q Other: _________________________________________________________
Would any practitioners in the practice like to be contacted to join a Passport Health Plan Committee?
q Yes q No
CREDENTIALING CONTACT INFORMATION
Credentialing Contact Name ___________________________________ Phone __________________________________
Fax __________________________________________ Email ___________________________________________________
Address ________________________________________________________________________________________________
City _____________________________________________ State _____________ Zip Code _______________________
IMPORTANT INFORMATION
To expedite processing please remember:
• Attach a W9
• Attach a MAP 811 with required attachments, if applicable
• Assure Passport Health Plan has access to retrieve the practitioner’s CAQH
• This form can returned to via email to Passport.Credentialing@passporthealthplan.com, via fax at 502-585-7987,
or via mail at: Attention: Provider Enrollment 5100 Commerce Crossings Drive Louisville, KY 40229
• Submit an Adding a Practitioner Form for each set up practitioner needs to be afliated with.
• KY Medicaid Requirements by provider type are available at http://chfs.ky.gov/dms/provEnr/
Provider+Type+Summaries.htm.
• KY Medicaid Enrollment Forms are available at http://chfs.ky.gov/dms/provEnr/Forms.htm.
• Passport Health Plan notices will be sent electronically via POIS (Passport Online Information Service)
and posted on our website at www.passporthealthplan.com.
• For questions regarding this form you may contact Provider Enrollment at
Passport.Credentialing@passporthealthplan.com.
_______________________________________________ ______________________________
NAME OF PERSON SUBMITTING REQUEST TITLE
_______________________________________________
PHONE
_______________________________________________
OFFICE EMAIL
For credentialing information, please call 502-588-8578 or email passport.credentialing@passporthealthplan.com.
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Adding A-practitioner Form

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Completed 16 July 2020

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