Provider Enrollment
  1. Provider Enrollment Form
  2. Provider s Name(*)
    Please type your full name.
  3. Gender(*)
    Invalid Input
  4. Providers Email(*)
    Invalid email address.
  5. Administrator Email
    Invalid email address.
  6. Practice Physical Address (PO Box is not accepted)(*)
    Invalid Input
  7. Address 2
    Invalid Input
  8. City(*)
    Invalid Input
  9. Zip Code(*)
    Invalid Input
  10. State(*)
    Invalid Input
  11. Telephone(*)
    Invalid Input
  12. Mobile
    Invalid Input
  13. Fax
    Invalid Input
  14. Preferred Contact Phone(*)
    Invalid Input
  15. NPI(*)
    Invalid Input
  16. PR Medical License(*)
    Invalid Input
  17. Same as practice address
    Invalid Input
  18. Mailing Address
    Invalid Input
  19. Address 2
    Invalid Input
  20. City
    Invalid Input
  21. Zip Code
    Invalid Input
  22. State
    Invalid Input
  23. Number of Support Staff in the practice:(*)
    Invalid Input
  24. Estimated number of patients encounters per year(*)
    Invalid Input
  25. Estimated number of unique patients per year(*)
    Invalid Input
  26.  
  1. Participating Provider Information
  2. Estimated percentage of patients:
  3. “Mi Salud” (Medicaid)(*)
    Invalid Input
      %
  4. Medicare Advantage(*)
    Invalid Input
      %
  5. Medicare Advantage Platino (*)
    Invalid Input
     %
  6. Commercial (Private)(*)
    Invalid Input
      %
  7. Medicare (FFS)(*)
    Invalid Input
      %
  8. Uninsured(*)
    Invalid Input
      %
  9. Total(*)
    Invalid Input

      % (The sum of all fields has to totalize 100%)

  10. Specialty(*)









    Invalid Input
  11. If "Other" please specify
    Invalid Input
  12. Provider Credentials(*)
















    Invalid Input
  13. Affiliations(*)




    Invalid Input
  14. Affiliated to the Following IPA(s)
    Invalid Input
  15. IPA Administrator’s Name:
    Invalid Input
  16. IPA Administrator’s Telephone #
    Invalid Input
  17.  
  1. Please indicate the status of Electronic Health Record (E.H.R.) adoption in your practice:
  2. I have already installed an E.H.R. program.(*)
    Invalid Input
  3. Is the E.H.R. program certified?(*)
    Invalid Input
  4. Product Name
    Invalid Input
  5. Version
    Invalid Input
  6. Go Live Date
    Invalid Input
  7. I am doing e-prescribing(*)
    Invalid Input
  8. I am interested in learning about certified E.H.R program options(*)
    Invalid Input
  9.  
  1. Provider practice autorization
  2. Name(*)
    Invalid Input
  3. Practice Position(*)
    Invalid Input
  4. Date(*)
    Please select a date when we should contact you.
  5. Signature

    Invalid Input
  6.    RefreshInvalid Input
  7.   
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