MEDICAL OFFICE PROVIDER ENROLLMENT FORM
Please complete and return via email to firstname.lastname@example.org
If you are unable to email this form, please fax it to 314-802-6913.
Please note the turnaround time for approval is 10 Business Days, you will be notified by
Email or Fax, if you have a preference please indicate on the form.
The information provided on this form MUST match what is on file with the payers.
Group Information (if applicable)
Pay To Address (if different)
***Indicate below the Individual and/or the Group Provider numbers, legacy ID’s or PTANS issued by the payers. ***
Although these IDs may not be used on the claims, they are often required for EDI enrollment.
Individual Provider Number
Intercommunity Health Net INCHN
SITE ID: 337G