Office Profile

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Please briefly explain your license request below

Who should we contact if we have questions about your application?

Name

Phone

Service Office Information

Service Office Name

Address Line 1

Address Line 2

City

Zip code

Office Type (Clinic, FQHC, School, etc.)

Office Contact Name

Office Phone

Office Fax

Can Fax Receive PHI? Yes No

Office Email Address

Location (Sub Part) NPI

Service Office Detail

Does the office have Public Transportation Access? Yes No

Handicap accessible exam rooms? Yes No

Is the office Handicap Accessible? Yes No

Handicap accessible equipment? Yes No

Handicap accessible lifts? Yes No

Does the office use Electronic Health Records? Yes No

Does the office offer TeleHealth Services? Yes No

Handicap / wheelchair access to building? Yes No

Does Your Office Provide Access to a Skilled Medical Interpreter? Yes No

Are Translation Services Available? Yes No

Handicap accessible lifts? Yes No

Handicap accessible scales? Yes No

Handicap accessible bathrooms, stalls, grab bar? Yes No

Does the office have accommodations for individuals with physical disabilities? Yes No

Business Information – New Tax IDs require a Contract and W9. Disclosure of Ownership is required for Medicaid networks.

Tax ID

Organizational (Type 2) NPI

Business Name

Business Email

Address Line 1

Address Line 2

City

Zip code

Business Phone

Business Fax

Website

Business Contact Name

Payment Information

Payment Address Line 1

Payment Address Line 2

City

Zip code

Payment Type? Paper Check EFT

Payment Contact Name

Regular Office Hours

Monday (a.m. to p.m.)

Tuesday (a.m. to p.m.)

Wednesday (a.m. to p.m.)

Thursday (a.m. to p.m.)

Friday (a.m. to p.m.)

Saturday (a.m. to p.m.)

Sunday (a.m. to p.m.)

Participating Providers

Please provide a list of all providers who will provide patient care at this location. (Attach a separate sheet if needed.)

Provider Name

Individual NPI

Provider Name

Individual NPI

Provider Name

Individual NPI

Signature

I hereby certify that the above information is true and accurate. I understand that the applicable network has complete discretion in accepting or rejecting my application. I also consent to the release of relevant information provided on this form to network’s clients and members for purposes of paying claims and referring members. I authorize Sun Life to obtain all information necessary to process my application.

I agree with the above certification and statements I agree

Name

Date

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