Section 1 instructions: Please complete all fields below for the provider.

Entity name (as written on W9): Provider type: □ PCP □ Specialist □ Behavioral health □ Urgent care □ FQHC □ RHC

Independent practice association (IPA) name (if applicable): Billing type: □ UB-04/institutional □ CMS 1500/professional

Name doing business as (if applicable): Group or facility TIN/EIN (nine characters):

Primary contact name:

Primary contact email: Primary contact phone:

Pay to (street address): Building or suite number: City, state, ZIP:

Recoveries address (if different from Pay to above): Building or suite number: City, state, ZIP:

Credentialing contact name:

Credentialing contact phone: Credentialing contact email:

Credentialing contact physical address (if different from main office location):

Organization website:

Section 2 instructions: Please complete each section below for all locations, including applicable NPI and Medicaid ID information. (Make additional copies if needed.)

LocationGroup name (as it should appear in a provider directory)

Street address Building or suite number City State ZIP code

+ 4 County Taxonomy code

CAQH registration number

Group or facility NPI and Medicaid ID

Phone with area code

Main practice location 1

NPI

Medicaid

Practice location 2

NPI

Medicaid

Practice location 3

NPI

Medicaid

Practice location 4

NPI

Medicaid

Practice location 5

NPI

Medicaid

Please feel free to attach an additional document if more space is required.

AmeriHealth Caritas New HampshireProvider Data Intake Form

Please email to providerenrollmentnh@amerihealthcaritas.com or fax 1-877-759-6189.

Page 1 of 10

AmeriHealth Caritas New Hampshire Provider Data Intake Form

Page 2 of 10

Section 3 instructions: Please complete all fields below by selecting which services are provided at each location from page 1 above. Please use the “Additional location information/notes” column for any special instructions related to the corresponding service (if any).

Servicess being provided (check all that apply) Additional location information/notes Locations

Acupuncture services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Adult family care □ All □ 1 □ 2 □ 3 □ 4 □ 5

Adult in-home services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Adult medical day services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Advanced practice registered nurse (APRN) □ All □ 1 □ 2 □ 3 □ 4 □ 5

Ambulatory surgical center (ASC) □ All □ 1 □ 2 □ 3 □ 4 □ 5

American Society of Addiction Medicine (ASAM) level 1: Outpatient services □ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5

ASAM level 1: Ambulatory withdrawal management □ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5

ASAM level 2.1: Intensive outpatient services □ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5

ASAM level 2.5: Partial hospitalization services □ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5

ASAM level 3.1: Clinically managed low-intensity residential services, adolescent □ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5

ASAM level 3.5: Clinically managed medium-intensity residential services, adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5

ASAM level 3.5: Clinically managed high-intensity residential services, adult □ All □ 1 □ 2 □ 3 □ 4 □ 5

ASAM level 3.7: Medically monitored residential withdrawal management□ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5

ASAM level 4: Medically monitored inpatient hospital withdrawal management □ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5

Please email to providerenrollmentnh@amerihealthcaritas.com or fax 1-877-759-6189.

AmeriHealth Caritas New Hampshire Provider Data Intake Form

Services(s) being provided: Check all that apply Additional location information/notes Locations

ASAM level OTS: Outpatient opioid treatment □ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5

Specialty residential services for pregnant and parenting women□ Adult □ Adolescent □ All □ 1 □ 2 □ 3 □ 4 □ 5

Assistive technology support services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Audiology services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Certified non-nurse midwife □ All □ 1 □ 2 □ 3 □ 4 □ 5

Child health support service □ All □ 1 □ 2 □ 3 □ 4 □ 5

Chiropractic services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Community mental health center □ All □ 1 □ 2 □ 3 □ 4 □ 5

Community participation services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Community support services (CSS) □ All □ 1 □ 2 □ 3 □ 4 □ 5

Community transition services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Consultations □ All □ 1 □ 2 □ 3 □ 4 □ 5

Crisis intervention □ All □ 1 □ 2 □ 3 □ 4 □ 5

Crisis response services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Developmental disabilities (DD) ages 0 – 21 □ All □ 1 □ 2 □ 3 □ 4 □ 5

DD and intellectual disabilities (ID) ages 0 – no max age □ All □ 1 □ 2 □ 3 □ 4 □ 5

Page 3 of 10Please email to providerenrollmentnh@amerihealthcaritas.com or fax 1-877-759-6189.

Services Additional location information/notes Locations

Dental □ All □ 1 □ 2 □ 3 □ 4 □ 5

Developmental services, early supports and services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Diabetes self-management □ All □ 1 □ 2 □ 3 □ 4 □ 5

Diagnostic imaging/X-ray □ All □ 1 □ 2 □ 3 □ 4 □ 5

Early and Periodic Screening, Diagnostic, and Treatment □ All □ 1 □ 2 □ 3 □ 4 □ 5

Early intervention □ All □ 1 □ 2 □ 3 □ 4 □ 5

Enhanced personal care □ All □ 1 □ 2 □ 3 □ 4 □ 5

Environmental accessibility services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Extended services to pregnant women □ All □ 1 □ 2 □ 3 □ 4 □ 5

Family planning □ All □ 1 □ 2 □ 3 □ 4 □ 5

Family support/service coordination □ All □ 1 □ 2 □ 3 □ 4 □ 5

Financial management services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Fluoride varnish by primary care provider (PCP) □ All □ 1 □ 2 □ 3 □ 4 □ 5

Federally qualified health center (FQHC) □ All □ 1 □ 2 □ 3 □ 4 □ 5

Furnished medical supplies and durable medical equipment □ All □ 1 □ 2 □ 3 □ 4 □ 5

Home-based therapy □ All □ 1 □ 2 □ 3 □ 4 □ 5

Home-delivered meals □ All □ 1 □ 2 □ 3 □ 4 □ 5

AmeriHealth Caritas New Hampshire Provider Data Intake Form

Page 4 of 10Please email to providerenrollmentnh@amerihealthcaritas.com or fax 1-877-759-6189.

Services Additional location information/notes Locations

Home health □ All □ 1 □ 2 □ 3 □ 4 □ 5

Home health aide □ All □ 1 □ 2 □ 3 □ 4 □ 5

Home modifications □ All □ 1 □ 2 □ 3 □ 4 □ 5

Home visiting services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Homemaker □ All □ 1 □ 2 □ 3 □ 4 □ 5

Hospice □ All □ 1 □ 2 □ 3 □ 4 □ 5

ID □ All □ 1 □ 2 □ 3 □ 4 □ 5

Intensive home and community services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Interpreter □ All □ 1 □ 2 □ 3 □ 4 □ 5

Lab □ All □ 1 □ 2 □ 3 □ 4 □ 5

Mammogram □ All □ 1 □ 2 □ 3 □ 4 □ 5

Medicaid in the Schools □ All □ 1 □ 2 □ 3 □ 4 □ 5

Medical nutrition □ All □ 1 □ 2 □ 3 □ 4 □ 5

Medical services clinic (e.g., opioid treatment program) □ All □ 1 □ 2 □ 3 □ 4 □ 5

Medical supplies □ All □ 1 □ 2 □ 3 □ 4 □ 5

Methadone clinic □ All □ 1 □ 2 □ 3 □ 4 □ 5

Newborn home visit □ All □ 1 □ 2 □ 3 □ 4 □ 5

AmeriHealth Caritas New Hampshire Provider Data Intake Form

Page 5 of 10Please email to providerenrollmentnh@amerihealthcaritas.com or fax 1-877-759-6189.

Services Additional location information/notes Locations

Non-emergency medical transportation (NEMT) □ All □ 1 □ 2 □ 3 □ 4 □ 5

Occupational therapy □ All □ 1 □ 2 □ 3 □ 4 □ 5

Optometric services/eyeglasses □ All □ 1 □ 2 □ 3 □ 4 □ 5

Participant-directed and -managed services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Personal care services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Personal emergency response system □ All □ 1 □ 2 □ 3 □ 4 □ 5

Pharmacy □ All □ 1 □ 2 □ 3 □ 4 □ 5

Physical therapy □ All □ 1 □ 2 □ 3 □ 4 □ 5

Placement services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Podiatry □ All □ 1 □ 2 □ 3 □ 4 □ 5

Prenatal child/family health care support □ All □ 1 □ 2 □ 3 □ 4 □ 5

Prescribed drugs □ All □ 1 □ 2 □ 3 □ 4 □ 5

Primary care services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Private duty nursing □ All □ 1 □ 2 □ 3 □ 4 □ 5

Private non-medical institution for children □ All □ 1 □ 2 □ 3 □ 4 □ 5

Psychology □ All □ 1 □ 2 □ 3 □ 4 □ 5

Psychotherapy □ All □ 1 □ 2 □ 3 □ 4 □ 5

Rehabilitative services post-hospital discharge □ All □ 1 □ 2 □ 3 □ 4 □ 5

AmeriHealth Caritas New Hampshire Provider Data Intake Form

Page 6 of 10Please email to providerenrollmentnh@amerihealthcaritas.com or fax 1-877-759-6189.

Services Additional location information/notes Locations

Residential care facility services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Residential habilitation/personal care services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Respite care □ All □ 1 □ 2 □ 3 □ 4 □ 5

Respite care for individuals with autism □ All □ 1 □ 2 □ 3 □ 4 □ 5

Rural health clinic (RHC) □ All □ 1 □ 2 □ 3 □ 4 □ 5

Service coordination □ All □ 1 □ 2 □ 3 □ 4 □ 5

Services including applied behavioral analysis coverage □ All □ 1 □ 2 □ 3 □ 4 □ 5

Specialist □ All □ 1 □ 2 □ 3 □ 4 □ 5

Specialized medical equipment □ All □ 1 □ 2 □ 3 □ 4 □ 5

Specialty services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Speech therapy □ All □ 1 □ 2 □ 3 □ 4 □ 5

Supported employment □ All □ 1 □ 2 □ 3 □ 4 □ 5

Supportive housing services □ All □ 1 □ 2 □ 3 □ 4 □ 5

Supportive housing services for aged individuals ages 65 – no max age and physically disabled and those with other disabilities ages 18 – 64 □ All □ 1 □ 2 □ 3 □ 4 □ 5

Targeted case management □ All □ 1 □ 2 □ 3 □ 4 □ 5

Ultrasound □ All □ 1 □ 2 □ 3 □ 4 □ 5

Urgent care □ All □ 1 □ 2 □ 3 □ 4 □ 5

AmeriHealth Caritas New Hampshire Provider Data Intake Form

Page 7 of 10Please email to providerenrollmentnh@amerihealthcaritas.com or fax 1-877-759-6189.

Services Additional location information/notes Locations

Wellness coaching for individuals with autism □ All □ 1 □ 2 □ 3 □ 4 □ 5

Wellness coaching for individuals with brain injury ages 22 – no max age □ All □ 1 □ 2 □ 3 □ 4 □ 5

Wheelchair van □ All □ 1 □ 2 □ 3 □ 4 □ 5

Telemedicine (primary care, medical, psych-telehealth)

*Please list the service types related to telemedicine in the fields provided.

□ All □ 1 □ 2 □ 3 □ 4 □ 5

□ All □ 1 □ 2 □ 3 □ 4 □ 5

□ All □ 1 □ 2 □ 3 □ 4 □ 5

□ All □ 1 □ 2 □ 3 □ 4 □ 5

Please add any unlisted services and indicate location. □ All □ 1 □ 2 □ 3 □ 4 □ 5

Additional provider notes (please list any additional information):

AmeriHealth Caritas New Hampshire Provider Data Intake Form

Page 8 of 10Please email to providerenrollmentnh@amerihealthcaritas.com or fax 1-877-759-6189.

Location number for practitioner First name Last name MI Degree/

licensure Specialty Age range

Is this practitioner accepting new patients?

Taxonomy code

Practitioner Medicaid ID, practitioner NPI, and CAQH registration number

Category

□ Adult □ Yes□ No

Medicaid □ PCP□ Specialist□ Hospital basedNPI

□ Child

CAQH number

□ Adult □ Yes□ No

Medicaid □ PCP□ Specialist□ Hospital basedNPI

□ Child

CAQH number

□ Adult □ Yes□ No

Medicaid □ PCP□ Specialist□ Hospital basedNPI

□ Child

CAQH number

□ Adult □ Yes□ No

Medicaid □ PCP□ Specialist□ Hospital basedNPI

□ Child

CAQH number

Section 4 instructions: Please complete all fields below related to the practitioner roster. Practitioner roster — please include practitioner licensures (e.g., MLADC, LPN, or APRN)

AmeriHealth Caritas New Hampshire Provider Data Intake Form

Page 9 of 10Please email to providerenrollmentnh@amerihealthcaritas.com or fax 1-877-759-6189.

ACNH_19429860

AmeriHealth Caritas New Hampshire Provider Data Intake Form

Location number for practitioner First name Last name MI Degree/

licensure Specialty Age range

Is this practitioner accepting new patients?

Taxonomy code

Practitioner Medicaid ID, practitioner NPI, and CAQH registration number

Category

□ Adult □ Yes□ No

Medicaid □ PCP□ Specialist□ Hospital basedNPI

□ Child

CAQH number

□ Adult □ Yes□ No

Medicaid □ PCP□ Specialist□ Hospital basedNPI

□ Child

CAQH number

□ Adult □ Yes□ No

Medicaid □ PCP□ Specialist□ Hospital basedNPI

□ Child

CAQH number

□ Adult □ Yes□ No

Medicaid □ PCP□ Specialist□ Hospital basedNPI

□ Child

CAQH number

Page 10 of 10Please email to providerenrollmentnh@amerihealthcaritas.com or fax 1-877-759-6189.