1. Name of person completing this form:
Full Name:
Title:
2. Provider Name (Practice Location Only):
3. Address:
4. City
State
Zip
5. E-mail Address for Person Completing this Form
6. County:
7. Practice Telephone: (ex. 888-343-3547)
8. Languages Spoken:
9. Primary Specialty:
10. Secondary Specialty:
11. Board Certified:
Degree:
12. Other locations:
13. Does the provider/group/facility render services in the member's home?
If "yes," go to question 13b.
13b. List all services rendered in the home:
14. Provider's Tax Identification Number:
15. Group Tax Identification Number (if applicable):
16. Legal Entity Name
17. How many providers are in the group? (if applicable)
Please list the first five:
1) Name of Provider:
Specialty:
NPI:
2) Name of Provider:
Specialty:
NPI:
3) Name of Provider:
Specialty:
NPI:
4) Name of Provider:
Specialty:
NPI:
5) Name of Provider:
Specialty:
NPI:
18. Group NPI #:
19. Is this Provider part of existing par-credentialed group?
Name:
20. Hospital Affiliations:
(a)
(b)
(c)
21. IPA Affiliations
(a)
(b)
(c)
22. Behavioral Health:
23. OMH/OASAS Facility?
24. Social Worker(s), if yes, please go to next question
25. R on your NYS License/Registration:
Notes:
26. As Fidelis Care has moved to a paperless environment, all providers are expected to submit and accept communications electronically. Are you willing and able to:

Submit claims electronically?
Accept electronic communications such as remittance advice (EOB) or member rosters?
27. How did you hear about Fidelis Care?
28. If you are a PCP, please advise us who you refer members to for specialty care:
(a)
(b)
(c)
(d)
(e)

*Note: Minimum Provider Qualifications: Valid, current license; valid current DEA certificate; completion of residency training; graduation from Medical/Professional school; certification; and hospital affiliation.

**Note: Pathologist, Radiologist, Anesthesiologists, Neonatologists, Emergency Medicine Physicians, Hospitalists, and Behavioral Health practitioners who practice exclusively within a State licensed facility (OMH or Article 28) do not have to be individually credentialed. Practitioners within these specialities who provide services independently of these facilities shall be individually credentialed.