P a g e | 2
APPLICATION FOR PROVIDER ENROLLMENT
To begin the enrollment process, please complete the information appropriate to your specialty. Complete and return with the
items on the attached checklist. All information must match NPPES.
Please ensure that your CAQH information is completed and released to us with the most up-to-date information.
Today’s Date: Requeste
d Effective Date: Group Name:
Group TAX ID: Group NPI: Provider Name:
Individual
NPI#:
SSN#:
DOB:
Gender:
Male
Female
Provider
License#/State:
DEA
Certificate#:
CAQH#:
MEDICAID
#:
Accepting
new
patients?
YES
NO
PCP?
YES
NO
Panel? OPEN
CLOSE
Language(s)
other
than
English:
Taxonomy Code (required). Circle One: MD DO PA NP Other: ____________________________
Primary Specialty: Taxonomy Code:
Second Specialty: Taxonomy Code:
Third Specialty: Taxonomy Code:
Please note: A correspondence street level address must be applied when a remittance address is a PO Box. Please use
additional sheets when needed for multiple addresses.
Address A
Street:________________________________________
_________________________________________
_________________________________________
___________ ________________________
STE:
City:
State:
ZIP
Code:
o Primary Office
o Additional Office
o Correspondence
o Remittance
o Medical Record
Phone:_____________________
_______________________
Fax:
Office Hours:
Handicap accessible: Y or N
Public
Transportation: Y
or N
Address B
________________________________________
________________________________________
_________________________________________
___________ ________________________
Street:
STE:_
City:
State: ZIP Code:
o Primary Office
o Additional Office
o Correspondence
o Remittance
o Medical Record
Phone:_____________________
Fax:___
____________________
Office Hours:
Handicap accessible: Y or N
Public
Transportation:
Y
or
N
5232 Witz Drive | N. Syracuse NY 13212
Attn: Provider Relations
P: 877-872-4716
F: 844-879-4509
E:
MHNYProviderServices@molinahealthcare.com
