Fillable PROV40464 PNM Practice Demographic Form

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PROV40464 PNM Practice Demographic Form

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The PROV40464 PNM Practice Demographic Form form is 1 page long and contains:

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  • 6 check-boxes
  • 23 other fields

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File type: PDF

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Please indicate which networks you are contracted for: q Medicaid q Medicaid AND Medicare
Practice NPI ____________________________________________________________________________________________
Practice Tax ID __________________________________________________________________________________________
Practice Name __________________________________________________________________________________________
Primary Address ________________________________________________________________________________________
City ______________________________ State ____________ Zip Code _________________ County ___________________
Primary Phone _________________________ Primary Fax ______________________
REMIT ADDRESS
Remit Address __________________________________________________________________________________________
City ______________________________ State ____________ Zip Code _________________ County ___________________
Remit Phone _____________________________________ Remit Fax _____________________________________________
OFFICE HOURS
Monday – Friday __________ ___________
FROM TO
OR
Specied Days and Times: _______________________________________________________________________________
PRACTICE LIMITATIONS IF APPLICABLE
q Male only q Female only
q Min age _________________ q Max age __________________
Other: _________________________________________________________________________________________________
PLEASE NOTE:
The Practice Demographic Form cannot be processed without attaching “Adding a Practitioner Form(s).”
For credentialing information, please call 502-588-8578 or email passport.credentialing@passporthealthplan.com.
PRACTICE DEMOGRAPHIC FORM
© 2015 PASSPORT HEALTH PLAN (PROV40464)
This form is applicable for Medicaid AND Passport
Advantage provider networks. YOU ONLY NEED TO
SUBMIT THIS FORM ONE (1) TIME.
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PROV40464 PNM Practice Demographic Form

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Completed 16 July 2020

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