Does the practitioner see members in an office setting? q Yes q No
Practitioner’s primary county location: ______________________________________________________________________
Please check one:
q Practitioner is a PCP
q Practitioner is a Specialist
Please add _________________________________, _____________________________ Effective _____________________
NAME TITLE DATE
Practitioner NPI # _________________________ Practitioner Taxonomy Code __________________________________
Practitioner Medicare # _________________ Practitioner Gender:
q M q F
Practitioner SSN # ____________________________________ Practitioner DOB __________________________________
Practitioner’s Specialty ___________________________________________________________________________________
Practitioner CAQH # ___________________________ Practitioner Office Hours __________________________________
Please check one:
q Practitioner has an active KY Medicaid ID. The Medicaid ID is ______________________________________________
q Practitioner has applied for a KY Medicaid ID. Medicaid ID is pending.
q Please assist in obtaining Practitioner’s Medicaid ID. MAP 811 is included.
Practice Name __________________________________________________________________________________________
Practice NPI __________________________________ Practice Taxonomy Code __________________________________
Passport Health Plan Group ID ____________________________________________________________________________
If this is a new solo set up or a new group set up a “Practice Demographic Form” is required to process this
practitioner add request.
Please check one:
q Practitioner practices only at primary address
q Practitioner practices at all addresses
q Other (List is attached with practice addresses specified)
Please check one:
q Group has an active KY Medicaid ID. The Medicaid ID is ___________________________________________________
q Group has applied for a KY Medicaid ID. Medicaid ID is pending.
q Please assist in obtaining Group’s Medicaid ID. MAP 811 is included.
ADDING A PRACTITIONER FORM
© 2014 PASSPORT HEALTH PLAN (PROV40464)
Tax ID ____________________ Tax Name _____________________________________
Tax Address _______________________________ Tax City ______________________________
Tax State _______ Tax Zip Code _______________ Tax Phone ___________________________
PANEL INFORMATION (IF APPLICABLE)
Age Limitations:
q MIN q MAX
Gender Limitations:
q Male Only q Female Only
Group Panel Status:
q OPEN q CLOSED
VOLUNTARY QUESTIONAIRE
Practitioner Ethnicity: q Non-Hispanic q Hispanic q Unknown
Practitioner Race:
q Black or African American q American Indian/Alaska Native q White
q Native Hawaiian/Other Pacific Islander q Other: _________________________________________________________
Would any practitioners in the practice like to be contacted to join a Passport Health Plan Committee?
q Yes q No
CREDENTIALING CONTACT INFORMATION
Credentialing Contact Name ___________________________________ Phone __________________________________
Fax __________________________________________ Email ___________________________________________________
Address ________________________________________________________________________________________________
City _____________________________________________ State _____________ Zip Code _______________________
IMPORTANT INFORMATION
To expedite processing please remember:
Attach a W9
Attach a MAP 811 with required attachments, if applicable
Assure Passport Health Plan has access to retrieve the practitioner’s CAQH
This form can returned to via email to Passport.Credentialing@passporthealthplan.com, via fax at 502-585-7987,
or via mail at: Attention: Provider Enrollment 5100 Commerce Crossings Drive Louisville, KY 40229
Submit an Adding a Practitioner Form for each set up practitioner needs to be afliated with.
KY Medicaid Requirements by provider type are available at http://chfs.ky.gov/dms/provEnr/
Provider+Type+Summaries.htm.
KY Medicaid Enrollment Forms are available at http://chfs.ky.gov/dms/provEnr/Forms.htm.
Passport Health Plan notices will be sent electronically via POIS (Passport Online Information Service)
and posted on our website at www.passporthealthplan.com.
For questions regarding this form you may contact Provider Enrollment at
Passport.Credentialing@passporthealthplan.com.
_______________________________________________ ______________________________
NAME OF PERSON SUBMITTING REQUEST TITLE
_______________________________________________
PHONE
_______________________________________________
OFFICE EMAIL
For credentialing information, please call 502-588-8578 or email passport.credentialing@passporthealthplan.com.
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