Ancillary Contract Request Form

Date

Please select Provider type

Line of Business

Amerivantage (Amerigroup)SCAN Health

Contact Name*

First NameLast Name

Contact Email*

example@example.com

Phone Number

Please enter a valid phone number.

Fax Number

Please enter a valid phone number.

Facility Name

Business/Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Office Phone Number

Please enter a valid phone number.

Office Fax Number

Please enter a valid phone number.

Office Email

example@example.com

Tax Identification Number

Medicare Number

Group NPI Number

Taxonomy Number

Billing Contact

Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Billing Phone Number

Please enter a valid phone number.

Billing Fax Number

Please enter a valid phone number.

Billing Email

example@example.com

Billing Form: Visit based or episodic

CMS 1500UB04

W9 & other documents

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Signature

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Ancillary Contract Request Form

Contact Information

Facility Information

Billing Information