AmeriHealth Caritas North Carolina Provider Data Intake Form Section 1 instructions: Please complete all fields below for the provider. Entity name (as written on W9): IPA name (if applicable): Category: PCP Ancillary Behavioral health MLTSS Urgent care FQHC RHC Name doing business as (if applicable): Provider TIN/EIN # (9 characters): Primary contact name: Primary contact email: Primary contact phone: Pay to: Street address: Building or suite number: City, state ZIP: Phone number: Section 2 instructions: Please complete each section below for all locations, including applicable and ID information. (Make additional copies if needed.) Location Main practice location 1 location 2 location 3 location 4 location 5 location 6 Group name (as it would appear in a provider directory) Street address Building or suite number City State ZIP + 4 digits County Taxonomy code Group / ID Phone with area code Page 1 of 2
Section 3 instructions: Please complete all fields below by inserting the number of practitioners for each provider type and number of locations for each facility type. Number of practitioners Category Provider type(s) Number of practitioners Category Allergy and immunology Anesthesiology Cardiology Dermatology Endocrinology Ear, nose, and throat/otolaryngology Gastroenterology General surgery Provider type(s) Orthopedic/orthopedic surgery Primary care providers Psychiatry and rehabilitation medicine Pulmonology Radiology Urgent care Urology Add additional provider types Hematology/oncology Nephrology Neurology/neurosurgery Obstetrics/gynecology Ophthalmology/optometry Pediatrician Therapy: occupational Therapy: physical Therapy: speech Page 2 of 6
Section 4 instructions: Please complete all fields below by selecting which service(s) are provided at each location from page 1 above. Please use the Additional location information/notes column for any special instructions related to the corresponding service (if any). care homes Ambulance services OR emergency response services (please circle the services that apply) Anesthesia services/pain management Assertive community treatment (ACT) Assisted living Behavior health Behavior support consultation Behavioral health professional and substance abuse services, evaluations, testing, assessments, medical management, and/or therapies Cardiovascular rehabilitation Chemotherapy birth education Chiropractic services Community transition services/transition assistance and supported emp Diagnostic imaging Dialysis Durable medical equipment/supplies Early and periodic screening, diagnosis, and treatment (EPSDT) End-stage renal disease services Facility-based crisis service for children and adolescents Family care homes Family planning and reproductive health services Family support (behavioral health) Habilitative and rehabilitative services occupational therapy Habilitative and rehabilitative services physical therapy Habilitative and rehabilitative services speech therapy Page 3 of 6
Health and behavior intervention Health department services Hearing aids and related evaluations Hemophilia services Home delivery meals Home health services/home health aide Home infusion therapy Home modifications Home visit for newborn care and assessment Home visit for postnatal assessment and follow-up care Hospice services Inpatient behavioral health services Intermediate care facilities for individuals with intellectual disabilities Intravenous outpatient services Laboratory services Maternal care skilled nurse home visit Medical supplies Medication-assisted treatment for opioid dependence Midwife services Nursing equipment and supplies Nursing facility services Nutritional evaluations and counseling dietary evaluation and counseling as medical Nutritional services Obstetrics/gynecology services Ophthalmology Optical services optometry Organ and tissue transplants Outpatient behavioral health services provided by direct-enrolled providers Page 4 of 6
Outpatient specialized therapy services Personal care services Physical rehabilitation equipment and supplies Podiatry services Private duty nursing, older than age 21 Private duty nursing, younger than age 21 Prosthetics and orthotics Psychiatric residential treatment facilities for children younger than age 21 Psychological services in health departments and school-based health centers sponsored by health departments to those younger than age 21 Pulmonary therapy Radiation therapy Radiology services Reconstructive surgery Recovery services (behavioral health) Rehabilitation service providers Reproductive health services Residential treatment services Respiratory equipment and supplies Respiratory therapy Respite School-based services Services for individuals with intellectual and developmental disabilities and mental health or substance abuse Skilled nursing facility Sleep studies Transportation Page 5 of 6
Telemedicine (primary care, medical, psych-telehealth) *Please list the service types related to telemedicine in the fields provided. Please add any unlisted services and indicate location. Section 5 instructions: Please complete all fields below related to the practitioner roster. Practitioner roster Location number for practitioner Waiver number (if applicable from number listed below)* First name Last name MI Degree Specialty CAQH reg. number Taxonomy code Group / ID Category ACNC_18192724 Page 6 of 6