Add a New Provider or Term an Existing ProviderWhat do you want to do? Add a New Provider Term a ProviderDo you need to term a single Specialist or multiple? Single Multiple If multiple practitioners' provider updates are needed, please download the EHP Roster Template and attach it in the upload field. All roster fields are required. EHP Roster Template (Excel)(Roster template revised 02/04/2022) New Provider Roster UploadChoose File Additional Files Needed: Copy of license, Copy of malpractice, Copy of NPI verification (if readily available)Choose File Update Requested ByFirst NameGroup TIN #Last NameContact EmailContact Phone NumberDate RequestedCommentsSpecialist NPI # Provider NameFirst NameLast NameTax ID #Practitioner will be termed from all locations associated with this TIN.Group/Facility Name Date Term EffectiveProvider Term Reason - Select -Left GroupRetiredDeceasedRelocated Out of StateClosed PracticeNo Longer Accepting MedicaidOtherReasonUpdate Requested ByFirst NameLast NameContact EmailContact Phone NumberDate RequestedCommentsDisclaimerIf you are terming more than 15 providers, you can submit your changes by emailing the details to EHPprovidercontracts@primehealthcare.comSpecialist NPI # Provider NameFirst NameLast NameTax ID #Practitioner will be termed from all locations associated with this TIN.Group/Facility Name Date Term EffectiveProvider Term Reason:- Select -Left GroupRetiredDeceasedRelocated Out of StateClosed PracticeNo Longer Accepting MedicaidOtherReasonUpdate Requested ByFirst NameLast NameContact EmailContact Phone NumberDate RequestedComments Add MoreSubmit Form
