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Contracted Provider Document Upload Form

What would you like to do? required *
What kind of provider are you? required *

Enroll a New Medical Practitioner

Have you attested on CAQH? required *
Have you authorized NH Healthy Families in CAQH? required *
Does your information in NPPES match the information on your enrollment request? required *
How many practitioners are in your practice? required *
Do you have or have you applied for a NH Medicaid ID? required *

Enroll a New Behavioral Health Practitioner

Have you attested on CAQH? required *
Have you authorized NH Healthy Families in CAQH? required *
Does your information in NPPES match the information on your enrollment request? required *
How many practitioners are in your practice? required *
Do you have or have you applied for a NH Medicaid ID? required *

Enroll a New Dual Practitioner

Have you attested on CAQH? required *
Have you authorized NH Healthy Families in CAQH? required *
Does your information in NPPES match the information on your enrollment request? required *
How many practitioners are in your practice? required *
Do you have or have you applied for a NH Medicaid ID? required *

Update a Medical Practitioner or Practice

Does your information in NPPES match the information on your enrollment request? required *

Update a Behavioral Health Practitioner or Practice

Does your information in NPPES match the information on your enrollment request? required *

Update a Dual Practitioner or Practice

Does your information in NPPES match the information on your enrollment request? required *