New DMEPOS Provider Requests

External Use Only

*If you need assistance, please reach out to the DMEPOS Provider Data Management Team at DMEPOSMCRproviderdatamanagement@carelon.com*

**For portal access please submit portal support form

*Please Submit a request for each provider location*

Provider Name:

Parent Name (if available):

*N/A if does not apply*

NPI

Tax ID

Do you bill place of service 12 (home), 13 (assisted living facility), and/or 14 (group home)?

Provider Contact Verification:

Provider Phone:

Provider Fax:

Do you have an authorization phone or fax number?

*This is separate from the location phone/fax*

Provider Contact Name:

Provider Contact Email:

Provider Contact Phone:

Phone

Provider Location Information:

Physical Street:

*This is for the physical address from which the product is shipped. Please do not supply your billing address or administrative office address.*

Physical City:

Physical State:

Physical Zip Code:

Additional Information:

Send me a copy of my responses