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.

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* Provider Name

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* Provider Type

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* TIN

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* Provider NPI

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* Address

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

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* Do you have another service location? (If yes, please fill out a separate form.)

Yes

No