www.integranethealth.com
Ancillary Network Request Form
Thank you for your interest in becoming an IntegraNet Health Ancillary Provider. Please complete this Ancillary Network Request Form, and attach a current W-9. A Representative will follow up via email of receipt of your request.
Date
-
Month
-
Day
Year
Date
Please select Provider type
ASC
DME
Clinical Lab
Dialysis Center
FQHC
Home Health
Hospital
Imaging
LTAC
SNF
Urgent Care
Other
Line of Business
Medicare Advantage Plans
Contact Information
Contact Name
*
First Name
Last Name
Contact Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Facility Information
Facility Name
Business/Service Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
Street Address
Street Address Line 2
City
State / 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 Information
Billing Contact
Billing Address
Street Address
Street Address Line 2
City
State / 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 1500
UB04
W9 & other documents
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