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Section 1 instructions: Please complete all fields below for the provider.
Entity name (as written on W9): Provider type: □ PCP □ Specialist □ Behavioral health □ Urgent care □ FQHC □ RHC
Independent practice association (IPA) name (if applicable): Billing type: □ UB-04/institutional □ CMS 1500/professional
Name doing business as (if applicable): Group or facility TIN/EIN (nine characters):
Primary contact name:
Primary contact email: Primary contact phone:
Pay to (street address): Building or suite number: City, state, ZIP:
Recoveries address (if different from Pay to above): Building or suite number: City, state, ZIP:
Credentialing contact name:
Credentialing contact phone: Credentialing contact email:
Credentialing contact physical address (if different from main office location):
Organization website:
Section 2 instructions: Please complete each section below for all locations, including applicable NPI and Medicaid ID information. (Make additional copies if needed.)
LocationGroup name (as it should appear in a provider directory)
Street address Building or suite number City State ZIP code
+ 4 County Taxonomy code
CAQH registration number
Group or facility NPI and Medicaid ID
Phone with area code
Main practice location 1
NPI
Medicaid
Practice location 2
NPI
Medicaid
Practice location 3
NPI
Medicaid
Practice location 4
NPI
Medicaid
Practice location 5
NPI
Medicaid
Please feel free to attach an additional document if more space is required.
AmeriHealth Caritas New HampshireProvider Data Intake Form
Please email to [email protected] or fax 1-877-759-6189.
Page 1 of 10
AmeriHealth Caritas New Hampshire Provider Data Intake Form
Page 2 of 10
Section 3 instructions: Please complete all fields below by selecting which services 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).
Servicess being provided (check all that apply) Additional location information/notes Locations
Acupuncture services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Adult family care □ All □ 1 □ 2 □ 3 □ 4 □ 5
Adult in-home services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Adult medical day services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Advanced practice registered nurse (APRN) □ All □ 1 □ 2 □ 3 □ 4 □ 5
Ambulatory surgical center (ASC) □ All □ 1 □ 2 □ 3 □ 4 □ 5
American Society of Addiction Medicine (ASAM) level 1: Outpatient services □ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5
ASAM level 1: Ambulatory withdrawal management □ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5
ASAM level 2.1: Intensive outpatient services □ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5
ASAM level 2.5: Partial hospitalization services □ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5
ASAM level 3.1: Clinically managed low-intensity residential services, adolescent □ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5
ASAM level 3.5: Clinically managed medium-intensity residential services, adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5
ASAM level 3.5: Clinically managed high-intensity residential services, adult □ All □ 1 □ 2 □ 3 □ 4 □ 5
ASAM level 3.7: Medically monitored residential withdrawal management□ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5
ASAM level 4: Medically monitored inpatient hospital withdrawal management □ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5
Please email to [email protected] or fax 1-877-759-6189.
AmeriHealth Caritas New Hampshire Provider Data Intake Form
Services(s) being provided: Check all that apply Additional location information/notes Locations
ASAM level OTS: Outpatient opioid treatment □ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5
Specialty residential services for pregnant and parenting women□ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5
Assistive technology support services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Audiology services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Certified non-nurse midwife □ All □ 1 □ 2 □ 3 □ 4 □ 5
Child health support service □ All □ 1 □ 2 □ 3 □ 4 □ 5
Chiropractic services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Community mental health center □ All □ 1 □ 2 □ 3 □ 4 □ 5
Community participation services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Community support services (CSS) □ All □ 1 □ 2 □ 3 □ 4 □ 5
Community transition services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Consultations □ All □ 1 □ 2 □ 3 □ 4 □ 5
Crisis intervention □ All □ 1 □ 2 □ 3 □ 4 □ 5
Crisis response services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Developmental disabilities (DD) ages 0 – 21 □ All □ 1 □ 2 □ 3 □ 4 □ 5
DD and intellectual disabilities (ID) ages 0 – no max age □ All □ 1 □ 2 □ 3 □ 4 □ 5
Page 3 of 10Please email to [email protected] or fax 1-877-759-6189.
Services Additional location information/notes Locations
Dental □ All □ 1 □ 2 □ 3 □ 4 □ 5
Developmental services, early supports and services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Diabetes self-management □ All □ 1 □ 2 □ 3 □ 4 □ 5
Diagnostic imaging/X-ray □ All □ 1 □ 2 □ 3 □ 4 □ 5
Early and Periodic Screening, Diagnostic, and Treatment □ All □ 1 □ 2 □ 3 □ 4 □ 5
Early intervention □ All □ 1 □ 2 □ 3 □ 4 □ 5
Enhanced personal care □ All □ 1 □ 2 □ 3 □ 4 □ 5
Environmental accessibility services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Extended services to pregnant women □ All □ 1 □ 2 □ 3 □ 4 □ 5
Family planning □ All □ 1 □ 2 □ 3 □ 4 □ 5
Family support/service coordination □ All □ 1 □ 2 □ 3 □ 4 □ 5
Financial management services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Fluoride varnish by primary care provider (PCP) □ All □ 1 □ 2 □ 3 □ 4 □ 5
Federally qualified health center (FQHC) □ All □ 1 □ 2 □ 3 □ 4 □ 5
Furnished medical supplies and durable medical equipment □ All □ 1 □ 2 □ 3 □ 4 □ 5
Home-based therapy □ All □ 1 □ 2 □ 3 □ 4 □ 5
Home-delivered meals □ All □ 1 □ 2 □ 3 □ 4 □ 5
AmeriHealth Caritas New Hampshire Provider Data Intake Form
Page 4 of 10Please email to [email protected] or fax 1-877-759-6189.
Services Additional location information/notes Locations
Home health □ All □ 1 □ 2 □ 3 □ 4 □ 5
Home health aide □ All □ 1 □ 2 □ 3 □ 4 □ 5
Home modifications □ All □ 1 □ 2 □ 3 □ 4 □ 5
Home visiting services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Homemaker □ All □ 1 □ 2 □ 3 □ 4 □ 5
Hospice □ All □ 1 □ 2 □ 3 □ 4 □ 5
ID □ All □ 1 □ 2 □ 3 □ 4 □ 5
Intensive home and community services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Interpreter □ All □ 1 □ 2 □ 3 □ 4 □ 5
Lab □ All □ 1 □ 2 □ 3 □ 4 □ 5
Mammogram □ All □ 1 □ 2 □ 3 □ 4 □ 5
Medicaid in the Schools □ All □ 1 □ 2 □ 3 □ 4 □ 5
Medical nutrition □ All □ 1 □ 2 □ 3 □ 4 □ 5
Medical services clinic (e.g., opioid treatment program) □ All □ 1 □ 2 □ 3 □ 4 □ 5
Medical supplies □ All □ 1 □ 2 □ 3 □ 4 □ 5
Methadone clinic □ All □ 1 □ 2 □ 3 □ 4 □ 5
Newborn home visit □ All □ 1 □ 2 □ 3 □ 4 □ 5
AmeriHealth Caritas New Hampshire Provider Data Intake Form
Page 5 of 10Please email to [email protected] or fax 1-877-759-6189.
Services Additional location information/notes Locations
Non-emergency medical transportation (NEMT) □ All □ 1 □ 2 □ 3 □ 4 □ 5
Occupational therapy □ All □ 1 □ 2 □ 3 □ 4 □ 5
Optometric services/eyeglasses □ All □ 1 □ 2 □ 3 □ 4 □ 5
Participant-directed and -managed services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Personal care services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Personal emergency response system □ All □ 1 □ 2 □ 3 □ 4 □ 5
Pharmacy □ All □ 1 □ 2 □ 3 □ 4 □ 5
Physical therapy □ All □ 1 □ 2 □ 3 □ 4 □ 5
Placement services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Podiatry □ All □ 1 □ 2 □ 3 □ 4 □ 5
Prenatal child/family health care support □ All □ 1 □ 2 □ 3 □ 4 □ 5
Prescribed drugs □ All □ 1 □ 2 □ 3 □ 4 □ 5
Primary care services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Private duty nursing □ All □ 1 □ 2 □ 3 □ 4 □ 5
Private non-medical institution for children □ All □ 1 □ 2 □ 3 □ 4 □ 5
Psychology □ All □ 1 □ 2 □ 3 □ 4 □ 5
Psychotherapy □ All □ 1 □ 2 □ 3 □ 4 □ 5
Rehabilitative services post-hospital discharge □ All □ 1 □ 2 □ 3 □ 4 □ 5
AmeriHealth Caritas New Hampshire Provider Data Intake Form
Page 6 of 10Please email to [email protected] or fax 1-877-759-6189.
Services Additional location information/notes Locations
Residential care facility services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Residential habilitation/personal care services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Respite care □ All □ 1 □ 2 □ 3 □ 4 □ 5
Respite care for individuals with autism □ All □ 1 □ 2 □ 3 □ 4 □ 5
Rural health clinic (RHC) □ All □ 1 □ 2 □ 3 □ 4 □ 5
Service coordination □ All □ 1 □ 2 □ 3 □ 4 □ 5
Services including applied behavioral analysis coverage □ All □ 1 □ 2 □ 3 □ 4 □ 5
Specialist □ All □ 1 □ 2 □ 3 □ 4 □ 5
Specialized medical equipment □ All □ 1 □ 2 □ 3 □ 4 □ 5
Specialty services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Speech therapy □ All □ 1 □ 2 □ 3 □ 4 □ 5
Supported employment □ All □ 1 □ 2 □ 3 □ 4 □ 5
Supportive housing services □ All □ 1 □ 2 □ 3 □ 4 □ 5
Supportive housing services for aged individuals ages 65 – no max age and physically disabled and those with other disabilities ages 18 – 64 □ All □ 1 □ 2 □ 3 □ 4 □ 5
Targeted case management □ All □ 1 □ 2 □ 3 □ 4 □ 5
Ultrasound □ All □ 1 □ 2 □ 3 □ 4 □ 5
Urgent care □ All □ 1 □ 2 □ 3 □ 4 □ 5
AmeriHealth Caritas New Hampshire Provider Data Intake Form
Page 7 of 10Please email to [email protected] or fax 1-877-759-6189.
Services Additional location information/notes Locations
Wellness coaching for individuals with autism □ All □ 1 □ 2 □ 3 □ 4 □ 5
Wellness coaching for individuals with brain injury ages 22 – no max age □ All □ 1 □ 2 □ 3 □ 4 □ 5
Wheelchair van □ All □ 1 □ 2 □ 3 □ 4 □ 5
Telemedicine (primary care, medical, psych-telehealth)
*Please list the service types related to telemedicine in the fields provided.
□ All □ 1 □ 2 □ 3 □ 4 □ 5
□ All □ 1 □ 2 □ 3 □ 4 □ 5
□ All □ 1 □ 2 □ 3 □ 4 □ 5
□ All □ 1 □ 2 □ 3 □ 4 □ 5
Please add any unlisted services and indicate location. □ All □ 1 □ 2 □ 3 □ 4 □ 5
Additional provider notes (please list any additional information):
AmeriHealth Caritas New Hampshire Provider Data Intake Form
Page 8 of 10Please email to [email protected] or fax 1-877-759-6189.
Location number for practitioner First name Last name MI Degree/
licensure Specialty Age range
Is this practitioner accepting new patients?
Taxonomy code
Practitioner Medicaid ID, practitioner NPI, and CAQH registration number
Category
□ Adult □ Yes□ No
Medicaid □ PCP□ Specialist□ Hospital basedNPI
□ Child
CAQH number
□ Adult □ Yes□ No
Medicaid □ PCP□ Specialist□ Hospital basedNPI
□ Child
CAQH number
□ Adult □ Yes□ No
Medicaid □ PCP□ Specialist□ Hospital basedNPI
□ Child
CAQH number
□ Adult □ Yes□ No
Medicaid □ PCP□ Specialist□ Hospital basedNPI
□ Child
CAQH number
Section 4 instructions: Please complete all fields below related to the practitioner roster. Practitioner roster — please include practitioner licensures (e.g., MLADC, LPN, or APRN)
AmeriHealth Caritas New Hampshire Provider Data Intake Form
Page 9 of 10Please email to [email protected] or fax 1-877-759-6189.
ACNH_19429860
AmeriHealth Caritas New Hampshire Provider Data Intake Form
Location number for practitioner First name Last name MI Degree/
licensure Specialty Age range
Is this practitioner accepting new patients?
Taxonomy code
Practitioner Medicaid ID, practitioner NPI, and CAQH registration number
Category
□ Adult □ Yes□ No
Medicaid □ PCP□ Specialist□ Hospital basedNPI
□ Child
CAQH number
□ Adult □ Yes□ No
Medicaid □ PCP□ Specialist□ Hospital basedNPI
□ Child
CAQH number
□ Adult □ Yes□ No
Medicaid □ PCP□ Specialist□ Hospital basedNPI
□ Child
CAQH number
□ Adult □ Yes□ No
Medicaid □ PCP□ Specialist□ Hospital basedNPI
□ Child
CAQH number
Page 10 of 10Please email to [email protected] or fax 1-877-759-6189.