Add Provider to My Existing Hospital Group

The entered values cannot be saved. Please see the fields below for details.

Group Information

Group Name: Required

Please enter a value.

Business Name: Required

Please enter a value.

Group NPI: Required

Requires 10 numerical characters.

Group TIN: Required

Requires 9 numerical characters.

State: Required

Completed By

Completed By Name: Required

Please enter a value.

Completed By Email: Required

Please enter email value in format 'mymail@domain.com'.

Completed By Phone: Required

Invalid phone number.

Phone Extension: Required

Example: (555) 555-5555 or 555-555-5555

Completed By Comments: Required

Please enter a value.

Provider Information

Provider First Name: Required

Please enter a value.

Provider Last Name: Required

Please enter a value.

Provider Specialty: Required

Please enter a value.

Provider Individual NPI: Required

Requires 10 numerical characters.

Effective Date of Addition: Required

Must be a valid date. Format: MM/DD/YYYY

Primary Location

Primary Location Name: Required

Please enter a value.

Primary Address: Required

Please enter a value.

Primary Phone: Required

Invalid phone number.

Example: (555) 555-5555 or 555-555-5555

Primary Fax: Required

Invalid phone number.

Example: (555) 555-5555 or 555-555-5555

Billing Location

Billing Location Name: Required

Please enter a value.

Billing Address: Required

Please enter a value.

Billing Phone: Required

Invalid phone number.

Example: (555) 555-5555 or 555-555-5555

Billing Fax: Required

Invalid phone number.

Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 1

Location 1 Name: Required

Please enter a value.

Location 1 Address: Required

Please enter a value.

Location 1 Phone: Required

Invalid phone number.

Example: (555) 555-5555 or 555-555-5555

Location 1 Fax: Required

Invalid phone number.

Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 2

Location 2 Name: Required

Location 2 Address: Required

Location 2 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 2 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 3

Location 3 Name: Required

Location 3 Address: Required

Location 3 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 3 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 4

Location 4 Name: Required

Location 4 Address: Required

Location 4 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 4 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 5

Location 5 Name: Required

Location 5 Address: Required

Location 5 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 5 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 6

Location 6 Name: Required

Location 6 Address: Required

Location 6 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 6 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 7

Location 7 Name: Required

Location 7 Address: Required

Location 7 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 7 Fax: Required

Example: (555) 555-5555 or 555-555-5555

Add This Location: Location 8

Location 8 Name: Required

Location 8 Address: Required

Location 8 Phone: Required

Example: (555) 555-5555 or 555-555-5555

Location 8 Fax: Required

Example: (555) 555-5555 or 555-555-5555

If you need to add more locations than permitted on this form, please complete another form for the remaining locations.

Add Provider to My Existing Hospital Group

Let's Talk

Want to learn more about HealthSmart?

We want to find the right solution for you.
Contact us for more information.

Add Provider to My Existing Hospital Group

Let's Talk

Want to learn more about HealthSmart?

We want to find the right solution for you. Contact us for more information.

We want to find the right solution for you.
Contact us for more information.