Provider Enrollment Form

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CMN
CORPORATE MEDICAL NETWORK
™
Provider Enrollment Form
Instructions
Please attach the following documents:
1. Complete this form and attach all requested documentation
‰ License or any local accreditation documentation
‰
2. Sign and date completed form
‰ Proof of Insurance
‰
3. Provider Enrollment Form must be submitted to:
‰ Copy of Fee Schedule
‰
or your designated Provider
Relations representative.
A. TYPE OF PROVIDER
‰
‰
‰
‰
Physician/Specialist
Dentist
Pharmacy
Occupational Health Services
B. PROVIDER INFORMATION
Provider Name
Physical Address
City
Region/State/Province
Postal / Zip Code
Country
Telephone (include area code)
Fax (include area code)
Website Address
(
)
(
)
Payee Name and Information (if different from above)
Billing/Payee Name
Billing/Payment Address
City
Region/State/Province
Postal / Zip Code
Country
Telephone (include area code)
Fax (include area code)
(
)
(
)
Languages - Please check all that apply
Medical Staff and Doctors
Administrative Staff
Medical Documentation
Claims
‰
‰
‰
‰
English
English
English
English
‰
‰
Translators
Translators
Other_____________________________
Other_____________________________
Other_____________________________
Other_____________________________
C. DEPARTMENTAL CONTACT INFORMATION
International Department
E-mail Address
Telephone (include area code)
(
)
Scheduling and Admissions
E-mail Address
Telephone (include area code)
(
)
Contracting
E-mail Address
Telephone (include area code)
(
)
Billing/Patient Accounts (Department Manager)
E-mail Address
Telephone (include area code)
(
)
Provider-Enrollment-Form
1
2013- 05-13

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