Paso 1 de 6 - Provider Information

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  • COMPLETING THIS PROVIDER ENROLLMENT APPLICATION IS A REQUIREMENT FOR PARTICIPATION IN THE MEDICAID PROGRAM, BUT DOES NOT GUARANTEE INCLUSION AS A NETWORK PROVIDER, AND IS NOT A SUBSTITUTE FOR A CONTRACT WITH A PARTICIPATING MANAGED CARE ORGANIZATION.

    BE AWARE OF THE INFORMATION PROVIDED. VALIDATE YOUR CONTACT EMAIL BEFORE GOING TO THE NEXT PAGE AND/ OR FINALIZING THE FORMULARY. ASES (PRHIA) IS NO RESPONSIBLE OF INFORMATION SEND IT TO THE WRONG CONTACT PERSON.

    Provider Information

  • 2. If Individual Provider

  • If Group Practice or Facility, Organization or Supplier

  • 3. Primary Service Address

  • 4. Mailing Address, if different

  • 5. National Provider Identifier (NPI) Number

  • 6. Additional Practice Location 1

    If you see patients in more than one practice location, please provide the service address and NPI number, if different, below. If you have more than three additional practice locations, attach a list with each service address and NPI number for each additional practice location to the Comments and Attachments section below.
  • Additional Practice Location 2

    If you see patients in more than one practice location, please provide the service address and NPI number, if different, below. If you have more than three additional practice locations, attach a list with each service address and NPI number for each additional practice location to the Comments and Attachments section below.
  • Additional Practice Location 3

    If you see patients in more than one practice location, please provide the service address and NPI number, if different, below. If you have more than three additional practice locations, attach a list with each service address and NPI number for each additional practice location to the Comments and Attachments section below.
  • 7. Medicare Provider Status

  • 8. Specialty

    Please enter the appropriate Medicare Specialty Code based on the CMS Provider Taxonomy Crosswalk available at the link
  • 9. Licenses

    Please list all federal and state health care licenses, permits or certifications. If you have more than three types of licenses, permits or certifications, attach a list of the license types and numbers for each additional license, permit or certification to the Comments and Attachments section below.
  • 10. Contact Information

    Please provide the following information for the appropriate person to contact with questions about your application.
  • 11. Network Providers

    If you have been contracted with a Managed Care Organization to provide services under the Puerto Rico Medicaid Program, please indicate for which Managed Care Organization you are providing services as a network provider.