Provider Setup & Access Request Form - CareBridge EVV


This form is designed to capture the information needed to begin the provider setup process within the CareBridge EVV solution, regardless of EVV vendor.


If your provider group has multiple Tax Identification Numbers (TIN), a form must be complete for each unique TIN. You can also reach out to CareBridge directly should you have multiple TINs and are in need of assistance.


The information provided will be used to set up your provider record.

It is critical that all the information provided is accurate.

Inaccurate information could result in delays.

Which state is this setup/access request for?


Note: If setup/access to multiple states is necessary, you will need to complete a Provider Setup & Access Request Form for each state.

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Iowa Providers

Please use the following link to request access to the CareBridge Provider Portal: https://ia.carebridgehealth.com/register-provider/new-registration

Arkansas Providers

Please use the following link to request access to the CareBridge Provider Portal:

https://ar.carebridgehealth.com/register-provider/new-registration

New Jersey Providers

Please use the following link to request access to the CareBridge Provider Portal:

https://nj.carebridgehealth.com/register-provider/new-registration

North Carolina Providers

Please use the following link to request access to the CareBridge Provider Portal:

https://nc.carebridgehealth.com/register-provider/new-registration

Tennessee Providers

Please use the following link to request access to the CareBridge Provider Portal:

https://tn.carebridgehealth.com/register-provider/new-registration

Wyoming Providers

Please use the following link to request access to the CareBridge Provider Portal:

https://wy.carebridgehealth.com/register-provider/new-registration

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