Answer Health Provider Data

This form is secured by SSL certificate/https

Verify or update the information we have previously collected to ensure your providers are listed correctly in our new referral application and practice directory

1Demographics and Referral Profile > 2Attestation
Provider No Longer w/ Practice

Check the box if the provider listed below is no longer employed at your practice. We will update our records accordingly.
Contact Information

To save this form and complete it at a later time, scroll to the bottom of the page & check "Save my progress and resume later"
No Changes Needed

Check the box if the provider listed below is no longer employed at your practice. We will update our records accordingly.
Office Name
Name Name Title First Middle Last Suffix
Enter Email Address

For shareholder communications - We will not Spam or sell your information
Date of Birth - YYYY-MM-DD
Degree / Credentials
NPI #
Primary Taxonomy Code
Membership Status
AH Communications (Email/Newsletters) Recipient

AH Communications (Email/Newsletters) Recipient Care Management Credentialing Contact Group Purchasing Lightbeam User Practice Portal User Office Manager Primary Office Contact Quality / Incentives RBE Communications Reporting

Types of communications/outreaches staff person should receive from Answer Health
Private Office Phone - (XXX) XXX-XXX
Cell Phone - (XXX) XXX-XXX
Upload Provider Photo

Attach Files
Primary Location

To save this form and complete it at a later time, scroll to the bottom of the page & check "Save my progress and resume later"
No Changes Needed

Check the box if the information listed below is accurate.
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Other Locations
Location 2 - Location 3 - Location 4 - Location 5 - Location 6 - Location 7 - Location 8 -
Specialty

To save this form and complete it at a later time, scroll to the bottom of the page & check "Save my progress and resume later"
Checkboxes

Checkboxes No Changes Needed

Check the box if the information listed below is accurate.
Practicing Specialty
Board Certified in Practicing Specialty
Specialty (Trained-in)
Board Certified in Specialty (Trained-in)
Secondary Specialty
Board Certified in Secondary Specialty
Tertiary Specialty
Board Certified in Tertiary Specialty
Licensing and Identifiers

To save this form and complete it at a later time, scroll to the bottom of the page & check "Save my progress and resume later"
No Changes Needed

Check the box if the information listed below is accurate.
MI License #
MI License Date Granted - YYYY-MM-DD
MI License Expiration Date - YYYY-MM-DD
MI License C-1 #
C-1 License Date Granted - YYYY-MM-DD
C-1 License Expiration Date - YYYY-MM-DD
MI License C-3 #
C-3 License Date Granted - YYYY-MM-DD
C-3 License Expiration Date - YYYY-MM-DD
DEA #
DEA # Date Granted - YYYY-MM-DD
DEA # Expiration Date - YYYY-MM-DD
Malpractice Coverage

To save this form and complete it at a later time, scroll to the bottom of the page & check "Save my progress and resume later"
No Changes Needed

Check the box if the information listed below is accurate.
Carrier
Policy #
Begin Date - YYYY-MM-DD
End Date - YYYY-MM-DD
Coverage Amounts
Riders
Salesforce Contact ID
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.

Answer Health Provider Data

Answer Health Provider Data

Contact Information

Primary Location

Specialty

Licensing and Identifiers

Malpractice Coverage