Group Provider Enrollment (Group Affiliation) Page

You use the Group Affiliation page to add or edit a group provider's affiliation to individual providers to the enrollment application.

Affiliation - Section 5 Fields

Field	Description
To add a new individual practitioner, click Add Affiliation. Existing affiliations, if any, are displayed in a table. To edit, in the Affiliations table, click the appropriate row. After changing or adding an individual practitioner, on the Affiliation action bar, click Save.
NH Title XIX Provider #	The New Hampshire Medicaid provider number of the practitioner that is affiliated with your group.
Name of Individual Practitioner	The name of the individual practitioner.
Effective Date of Affiliation	Date the group affiliation began. Format: MM/DD/YYYY, or click the calendar to select.