Home Health Agency Information Form


 A W9 is required prior to submitting your Agency Information Form For questions please contact: providerdatamanagement@carelon.com


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


*This is for Home Health Providers only*


*For Post Acute Care providers- use the link provided below

https://app.smartsheet.com/b/form/047afcfc11f6462eaede85ded91e1743*


*For DMEPOS Providers- use this link provided: https://app.smartsheet.com/b/form/ad7f5e8a5cbe49889d0d4e2b4960f394*


*If you need assistance completing this form, please reach out to providerdatamanagement@carelon.com*

Agency Information

*This is for MEDICARE ONLY, does not apply to Medicaid certification*

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*Only enter your 6 digit Medicare number*

Site Location Information

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Phone

(i.e. 8336096292)

Phone

*This is a different number from location phone and fax.*

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Phone
Phone
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Member Information

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Agency Contact Information

'Who is submitting this request?'

*Our preference is company domain email addresses. Non-company related domain such as Gmail and/or Yahoo will be validated.*

Phone

*Please provide all contacts with email address within your agency that are authorized to update agency information.*

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

Drag and drop files here or

https://providers.carelonmedicalbenefitsmanagement.com/postacute/provider-materials/

Would you like to join the Carelon network?*

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

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

*If you receive an error message, please confirm that all required fields are completed*

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