Form Pro-4 - Provider Recrutmt (Request To Particpate) printable pdf download

Rep Name: _______________________________________

For Internal Use Only

1199SEIU Benefit Funds

Provider Recruitment Form (Request to Participate)

Member Choice Credentialing Department • Times Square Station • PO Box 1009, New York, NY 10108-1009

(Please type or print in black or blue ink.)

Provider Information



Please send me information on becoming an 1199SEIU Participating Provider.

Date ________________________________________________

Full Legal Name* _________________________________________________________________________________________

Group/Practice Name_________________________________ Tax Identification No.* ______________________________

Office Address* __________________________________________________________________________________________

City* ________________________________________________State* ___________________ Zip Code* ________________

Office Telephone* ___________________________________ Office Fax _________________________________________

Office Contact _______________________________________Email _____________________________________________

Credentialing Contact ________________________________ Phone_________________ Email ______________________

Provider Specialty* _______________________________________________________________________________________

Board Status ____________________________________________________________________________________________

Individual National Provider Identifier (NPI) _________________________________________________________________

Hospital Affiliation ________________________________________________________________________________________

CAQH ID ____________________________________________ Date of Birth (for secondary validation)* _______________

* Required Field

Member Information



I want the Funds to contact my doctor listed above so he or she can become an 1199SEIU Participating Provider.

Full Name _______________________________________________________________________________________________

Institution _______________________________________________________________________________________________

Telephone _______________________________________________________________________________________________

Please mail, fax or email completed form to:

1199SEIU Benefit Funds

(Please allow 45 days from receipt to process your

Provider Relations Department

complete request.)

Contracting and Network Management

This document is not an application but a request for

330 West 42nd Street, 29th Floor

participation. It is subject to Funds’ network adequacy

New York, NY 10036-6977

guidelines. If you participate with CAQH, you must supply

Fax: (646) 473-7213 | Email:

your CAQH ID and NPI or date of birth.

PR04 • 6/16

Form Pro-4 - Provider Recrutmt (Request To Particpate)