Provider Information Sheet - One Health
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1PROVIDER INFORMATION SHEET
DATE OF COMPLETION:
PRACTICE NAME:
TAX ID
MAILING ADDRESS:
ADDRESS
Street
City
St
Zip
PHONE
FAX
CONTACT/EMAIL
BILLING/REMIT ADDRESS: □
Same as above
ADDRESS
Street
City
St
Zip
PHONE
FAX
CONTACT/EMAIL
CREDENTIALING ADDRESS: □
Same as above
ADDRESS
Street
City
St
Zip
PHONE
FAX
CONTACT/EMAIL
---------------------------------------------------------------------------------------------------------------------------------------
SITE LOCATION(S) ADDRESS:
[1] ADDRESS
Street
City
St
Zip
PHONE
FAX
CONTACT/EMAIL
PROVIDERS PRACTICING AT ADDRESS 1. PROVIDE NAME AND SPECIALTY:
1.
2.
3.
4.
---------------------------------------------------------------------------------------------------------------------------------------
[2] ADDRESS
Street
City
St
Zip
PHONE
FAX
CONTACT/EMAIL
PROVIDERS PRACTICING AT ADDRESS 2. PROVIDE NAME AND SPECIALTY:
1.
2.
3.
4.
---------------------------------------------------------------------------------------------------------------------------------------
[3] ADDRESS
Street
City
St
Zip
PHONE
FAX
CONTACT/EMAIL
PROVIDERS PRACTICING AT ADDRESS 3. PROVIDE NAME AND SPECIALTY:
1.
2.
3.
4.
*IF MORE THAN 3 SITE LOCATIONS OR MORE THAN 4 PROVIDERS AT ANY LOCATION, PLEASE ATTACH A COMPLETE
LISTOF SITE LOCATIONS WITH CORRESPONDING PROVIDERS AND SPECIALTIES. □ Site Roster attached.
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