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.
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome