Credentialing Application Disability Supplement I. Provider Information Please fill out the criteria below and return one form for each Group Practice/Clinic/Service Location where you serve members. OK Question Title * Provider Name OK Question Title * Provider Type Agency Ancillary Clinic DME Dental FQHC Free Standing Laboratory Group Practice Group Home Hospital Individual Provider PPG Pharmacy RHC Vision OK Question Title * TIN OK Question Title * Provider NPI OK Question Title * Address Address * Address 2 City/Town * State/Province * ZIP/Postal Code * OK Question Title * Do you have another service location? (If yes, please fill out a separate form.) Yes No OK NEXT