Request Enrollment Package (Individual or Group Provider) Page
You use the Request Enrollment Package page to request a provider enrollment package in the mail.
The Request Enrollment Package page contains the following panels:
Application Type Information Field
| Field | Description |
|---|---|
| Application Type |
Type of provider enrollment application you are requesting (individual or group). Tip: If requesting both, you must request each package separately. |
Address Information Fields
| Field | Description |
|---|---|
| On the Request Enrollment Package form, * indicates the field is required. | |
| Organization | Name of the individual or group organization requesting enrollment. |
| Last Name | Last name of the person requesting enrollment. |
| First Name | First name of the person requesting enrollment. |
| Middle Initial | Middle initial of the person requesting enrollment. |
| Title | Title of the person requesting enrollment. |
| Address Line 1 | Physical street address where you want the enrollment package sent to. |
| Address Line 2 | More specific address information. |
| City | City where the package is requested. |
| State | State where the package is requested. |
| Zip | Zip code and extension where the package is requested. |
| Phone | Phone number of the location where the package is requested. |
| Ext | Extension of the where the package is requested. |
| Attn | Department or person the package is to be sent to. |
| Contact Last Name | Last name of the location's contact person. |
| Contact First Name | First name of the location's contact person. |
| Contact Phone | Phone number of the contact person. |
| Ext | Phone extension of the contact person. |