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PROVIDER ADDITION REQUEST

Before Health Plan of Nevada and Sierra Health and Life can add the following provider to your group, the following form must be completed in full. The provider must hold a valid license in the state of their primary location.

* Indicates a required field

    New Provider Information

    The Name (Last, First, Middle): field is required.
    Title
    The Title: field is required.
    The Date of Birth (MM/DD/YYYY): field is required.
    The Effective Date with Group: field is required.
    The NPI # field is required.
    The Billing Tax ID Number: field is required.

    Provider Type

    Credentialing application not required if either is selected:

    If either option is selected, you must download and complete this form and attach it with your online submission.

    CAQH

    If you are not enrolled in CAQH, download enrollment instructions here.

    Group or Practice Information

    The Primary Name of Group or Practice: field is required.
    The Primary Specialty: field is required.
    Line(s) of Business to Add:
    The Line of business: field is required
    The Office Hours (Open/close times and days of week. Please be specific for each location.) field is required.
    The PRIMARY LOCATION, Street Address: field is required.
    The City: field is required.
    The State: field is required.
    The ZIP Code: field is required.

    Credentialing Information

    The Credentialing Contact, Name: field is required.
    The Email: field is required.
    The Phone: field is required.

    Hospital Admit Plan

    Physician has hospital privileges?
    The Physician has hospital privileges? field is required.
    Provider will only be rendering outpatient services?
    if there is an emergency in your office, what is your admit plan?

    Outpatient Surgery Plan*

    N/A

    * Providers who perform surgeries on an outpatient basis are required to have privileges at a plan contracted Ambulatory Surgery Center.

    If the information submitted on this application is false, inaccurate, inappropriate or incomplete, the application will be withdrawn or will not be considered for enrollment in the network.

    Thank you.