We've updated the Provider Information Form

Based off feedback from our providers, we’ve updated our Provider Information Form (PIF) to improve data collection of your provider and office information. The updated form is available at here.

With the new form, you can:

  • Declare the organization they are joining under. If a your part of a provider organization (PO), physician-hospital organization (PHO), or a clinically integrated network (CIN) you can provider that organization's name.
  • Add additional addresses. Just attach additional address to the form when you submit it.
  • Find supporting forms attached to the PIF. To provide efficiency for you we added the Medicaid Disclosure Requirement Form for Medicaid Network Providers, the Children's Special Health Care Services Provider Attestation, and the Children’s Special Health Care Services Provider Group Attestation forms to the PIF.
  • Sign an acknowledgement of the participation agreement on the PIF. Providers who are required to sign an acknowledgment of the participation agreement can now use the PIF to fulfill that requirement.