Provider Enrollment Form

Business Name

Contact Number

Servicing members for more than one state? Yes

Note: Colorado dental providers enrolling in a Medicaid plan need to enroll with the State of Colorado

Nevada Providers: Please email PPOInfoRequests@Sunlife.com to join our network.

Provider’s Individual NPI

Tax ID Number(s)

CAQH ID

Participating Network Types (select all that apply) Medicaid Adult Medicaid Child Special Needs CHIP Medicare Advantage Commercial Marketplace

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