PROVIDER RECRUITMENT FORM (REQUEST TO PARTICIPATE)
Please print clearly in blue or black ink, or complete online.
PROVIDER INFORMATION
Please complete this section and MAIL to: Provider Relations Department, Contracting and Network Management
498 Seventh Avenue, 7th Floor, New York, NY 10018-0009
or FAX to: (646) 473-7213
or EMAIL to: Providers@1199Funds.org
(Please allow 45 days from receipt for processing.)
Please send me information on becoming an 1199SEIU Participating Provider. _____________________ *Required field
DATE (MM/DD/YYYY)
____________________________________________________________________________________________________________________________
PROVIDER’S LEGAL NAME* PROVIDER'S DATE OF BIRTH (FOR SECONDARY VALIDATION) (MM/DD/YYYY)*
____________________________________________________________________________________________________________________________
GROUP/PRACTICE NAME TAX ID #*
____________________________________________________________________________________________________________________________
OFFICE ADDRESS* CITY* STATE* ZIP CODE*
____________________________________________________________________________________________________________________________
OFFICE PHONE* OFFICE FAX
____________________________________________________________________________________________________________________________
OFFICE CONTACT* PROVIDER'S EMAIL ADDRESS*
____________________________________________________________________________________________________________________________
CREDENTIALING CONTACT* CREDENTIALING CONTACT'S PHONE
____________________________________________________________________________________________________________________________
CREDENTIALING CONTACT'S EMAIL ADDRESS*
____________________________________________________________________________________________________________________________
PRIMARY SPECIALTY* SECONDARY SPECIALTY
____________________________________________________________________________________________________________________________
BOARD STATUS INDIVIDUAL NATIONAL PROVIDER IDENTIFIER (NPI)—MUST BE 10 DIGITS*
____________________________________________________________________________________________________________________________
HOSPITAL AFFILIATION CAQH ID #*
I attest that my CAQH attestation is within 120 and not older than 180 days. My Malpractice Insurance Certificate and other credentialing items are current
in CAQH. I hereby authorize the 1199SEIU Funds to access my CAQH profile.
If you are a nurse practitioner, you must have a New York State nurse practitioner collaboration agreement/arrangement/protocol.
X __________________________________________________________________________________________________________________________
PROVIDER'S SIGNATURE DATE (MM/DD/YYYY)
MEMBER INFORMATION
Please complete this section and give the form to your doctor. Your doctor will complete the Provider Information section above and submit the form to the Funds.
I want the Funds to contact my doctor listed above so he or she can become an 1199SEIU Participating Provider.
____________________________________________________________________________________________________________________________
MEMBER'S FULL NAME (FIRST AND LAST) MEMBER'S PREFERRED PHONE
____________________________________________________________________________________________________________________________
EMPLOYER NAME
This document is not an application, but a request for participation. It is subject to the Funds’
network adequacy guidelines. In order to apply for participation with the Funds, you MUST
participate with CAQH. The Funds only accept CAQH participants' applications. Please ensure
that you have authorized the Funds to have access to your CAQH data.
1199SEIU Benefit Funds ▪ www.1199SEIUBenefits.org
PR04 • 07/20 • PROVIDER RECRUITMENT
FOR INTERNAL USE ONLY
Rep name: ________________________________
Manager approval: __________________________
Provider ID or Validation Check (initials) ____________
Group contract on file Yes No
