SDoH Provider Request

SDoH Provider Request

For questions, please contact: providerdatamanagement@carelon.com

*For multiple sites please submit a request for each location.*

Provider Information

Legal Name (Provider Name)*

DBA Name*

*N/A if non-applicable*

Parent Company*

*N/A if non-applicable*

Medicare #

Provider NPI Number*

Provider Tax I.D #*

Location Information

Physical Street Address*

Physical City*

Physical State*

Select

Zip Code (5 digit)*

Site County*

Location Phone*

Phone

Location Fax*

*Secure fax numbers as member/patient information may be sent via fax.*

Phone

Authorization Information

Submitted by Email*

*Please type out email address in full*

Do you have an authorization phone or fax number?*

*This is separate from the location phone or fax.*

Select

Authorization Phone

Phone

Authorization Fax

*Secure fax numbers as member/patient information may be sent via fax.*

Phone

Contact Name*

Authorization Contact Email*

Network Information

Counties Served*

Would you like to join the myNEXUS network?*

Click below to have a member of our Contracting Team contact you.

Select

W9 Upload

Please note: A W9 is REQUIRED in order to complete your agency information form.

Drag and drop files here or

I attest that the information provided within this form is true and accurate

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