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Provider Enrollment Form

_____________________________________________________________________________________________

Provider’s Name: *

Gender *

Male

Female

Provider’s Email: *

Administrator’s Email:

Practice Address: *

Address 2:

City *

Zip Code *

State *

Phone # *

Mobile #

Fax #

Practice Contact Person:

Preferred Contact Phone # *

NPI: *

PR Medical License #: *

Mailing Address:

Address 2:

City

Zip Code

State

Number of Support Staff in the practice: *

Estimated number of patients encounters per year: *

Estimated number of unique patients per year: *

Participating Provider Information

_____________________________________________________________________________________________

Estimated percentage of patients with: (The sum of all fields has to totalize 100%)

“Mi Salud” (Medicaid) *

Medicare Advantage *

Medicare Advantage Platino *

Commercial (Private) *

Medicare (FFS) *

Uninsured *

Specialty: *

General Practice

Geriatrics

Pediatrics

Adolescent Medicine

Family Practice

Gynecology

Internal Medicine

OB-GYN

Other

If "Other" please specify

Provider Credentials: *

CNMW

DDM

DPM

DMD

DO

RN

MSW

NP

DC

PsyD

PT

LD

OD

DDS

MD

None

Affiliations: *

None

Physician Hospital Organization (PHO)

Physician Organization

Independent Practice Association (IPA)

Affiliated to the Following IPA(s):

IPA Administrator’s Name:

IPA Administrator’s Telephone #:

Please indicate the status of Electronic Health Record (E.H.R.) adoption in your practice:

I have already installed an E.H.R. program. *

Yes

No

Is the E.H.R. program certified?

Yes

No

Not Sure

Product Name:

Version:

Go Live Date:

I am doing e-prescribing. *

Yes

No

I am interested in learning about certified E.H.R program options. *

Yes

No

Provider practice autorization:

Name: *

Practice Position: *

Date:( dd/mm/year ) *

Signature *

I certify that the information provided in this form is correct and accurate. Please contact me for any corrections related to this information.

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