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

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.*

Contact Name

Authorization Contact Email

Network Information

Counties Served

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W9 Upload

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

Drop your files here

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

I attest

Send me a copy of my responses