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Application Request
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Application Request
Provider Application Request
Provider Application Request
Mailing Address has been validated via USPS and auto-corrected. Please review Mailing Address, City, State, Zip Code for accuracy and then click SUBMIT to continue.
Completion of this application request form indicates your interest only. You will be contacted by a Provider Relations Representative regarding next steps.
Note: Completion of this form is not part of the credentialing application for the network participation.
Fields marked with an
*
must be completed.
First Name
*
Required
Last Name
*
Required
Primary Specialty
*
Adult Day Health Services
Certified Nurse Practitioner
Physical Medicine and Rehab
Physical Therapy
Physician Assistant
Podiatry
Prosthodontics
Psychiatric Hospital
Psychiatry
Psychiatry, Child
Psychiatry, Geriatric
Psychology
Chiropractic
Psychology, Child
Pulmonary Diseases
Radiation Oncology
Radiology
Radiology, Nuclear
Radiology Facility
Radiology- Mobile Unit
Residential Care / Assist Living Fac
Residential Treatment Center
Respite Care
CMHC
Retinal Diseases
Rheumatology
Rural Health Clinic
Skilled Nursing Facility
Sleep Disorders
Speech Therapy / Pathology
Sports Medicine
State Regional Mental Health Institute
Sub-Acute Care / Intermediate Care Fac
Substance Abuse
Community Service Board
Surgery, Cardiothoracic/Cardiovascular
Surgery, Colon and Rectal
Surgery, Critical Care
Surgery, Endoscopic
Surgery, General
Surgery, Hand
Surgery, Head and Neck
Surgery, Neurological
Surgery, Oculoplastic
Surgery, Oncologic
County Health Department
Surgery, Oral / Maxillofacial
Surgery, Orthopedic
Surgery, Plastic
Surgery, Thoracic / Vascular
Surgery, Urological
Transportation
Urgent Care Center
Urology
Vision Care Services
Wound Care Center
Critical Care Medicine
Client Training
Enhanced Residential Care
Medicaid Personal Care
Nurse Delegation
Home and Community Based Services (HCBS)
Personal Assistance Service
Personal Care Services
Pest Control
Assistive Services
Hearing Aids
Dermatology
Applied Behavioral Analyst
Independent Assessor
Permanent Supportive Housing
Dialysis
Dietitian / Nutritionist
Durable Medical Equipment and Supplies
Allergy / Immunology
Early Childhood Intervention
Emergency Medicine
Endocrinology / Metabolism
Endodontics
Family Dentistry
Family Planning Services
Family Practice
Family Practice Nurse Practitioner
Federally Qualified Health Center
Gastroenterology
Ambulance
General Practice
Genetics
Geriatric Medicine
Gynecologic Oncology
Hematology / Oncology
H I V Specialist
Home Health Agency
Home Infusion Therapy
Hospice Care
Hospital
Ambulatory Surgery Center
Hospitalist
Infectious Diseases
In-Home Respiratory Care
Inpatient Mental Health / Sub Abuse
Inpatient Rehab Hospital
Intermediate Care Facility
Internal Medicine
Laboratory
Licensed Clinical Social Worker
Licensed Marriage/Family Therapist
Anesthesiology
Licensed Professional Counselor
Maternal / Fetal Medicine
Midwifery
Neonatal / Perinatal Medicine
Nephrology
Neurology
Neuropathology
Neuropsychology
Nuclear Medicine
Nursing Home
Anesthetist, Nurse
Nursing Services
Ob/Gyn Nurse Practitioner
Obstetrics / Gynecology
Occupational Therapy
Ophthalmology
Optical Dispensers
Optometry
Orthodontics
Orthotics and Prosthetics
Osteopathic Manipulative Medicine
Audiology
Other
Otolaryngology
Outpatient Mental Health / Sub Abuse
Outpatient Rehabilitation Center
Pain Management
Pathology
Pediatric Allergy / Immunology
Pediatric Cardiology
Pediatric Critical Care Medicine
Pediatric Dentistry
Cardiology
Pediatric Emergency Medicine
Pediatric Endocrinology
Pediatric Gastroenterology
Pediatric Hematology / Oncology
Pediatric Infectious Diseases
Pediatric Nephrology
Pediatric Neurology
Pediatric Nurse Practitioner
Pediatric Ophthalmology
Pediatric Orthopedic Surgery
Centers of Excellence HIV/AIDS
Pediatric Otolaryngology
Pediatric Pathology
Pediatric Pulmonology
Pediatric Rheumatology
Pediatrics
Pediatrics, Developmental
Pediatric Surgery
Pediatric Urology
Periodontics
Pharmacy
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Practice/Group Name
Primary Practice Address
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City
State
Zip Code
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County
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Office Phone
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Fax
Fax should be all numeric characters in format xxx-xxx-xxxx
Email Address
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Contact Person
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NPI
NPI should be 10- digit numeric characters
CAQH ID
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CAQH
Amerigroup accepts CAQH applications.
More about CAQH
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Application Request
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Iowa
Maryland
New Jersey
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Tennessee
Texas
Washington