Provider Application – Other Provider Types Instructions: Please complete the below application and provide comments as appropriate. All information is confidential. Required fields are marked with an asterisk (*) The information entered on this page can be saved to allow for completion at a later date. Incomplete requests will automatically delete from the system after 30 days of inactivity. Date* MM slash DD slash YYYY Contact Name* Contact Title* Contact Phone Number*Contact Email Address* Enter Email Confirm Email Section 1: Provider InformationProvider Name* Include First Name, Middle Initial, and Last NameSpecialty* NPI (Type I)* 10 Digit NumberDegree* Section 2: Practice/Facility InformationPractice/Facility Name* Title Role of Practice Owner (i.e., Director, CEO, etc.)Practice Owner's Full Name NPI (Type II)* 10 Digit NumberTax ID* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Office Phone Number*Extension Mailing Address (If different than above) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Website URL Start with https://Section 3: Other Provider InformationHas the provider ever been excluded from participating with Medicare/Medicaid*Has the provider ever been excluded from participating with Medicare/Medicaid *YesNoPer regulatory requirements any provider who is excluded from participation with Medicaid and/or Medicare is unable to join the network. We encourage you to apply in the future should circumstances change. Provider group and its practitioners are enrolled with Rhode Island Medicaid*Provider group and its practitioners are enrolled with Rhode Island Medicaid *YesNoPer federal requirements, all providers participating in the Neighborhood network are required to be enrolled with Rhode Island Medicaid. If you are currently not enrolled with Rhode Island Medicaid, please visit the Rhode Island Executive Office of Health and Human Services Provider Enrollment Page for additional information on how to enroll: Rhode Island Medicaid Provider Enrollment Application. If you have any questions please address them in the below section.Please Attach A Current W-9. W-9 Must have been completed within 6 months of today’s date.*Accepted file types: pdf, Max. file size: 10 MB. Submission of this form does not guarantee participation in the Neighborhood Health Plan of Rhode Island network. CAPTCHA