Group Practice Application
Current copies of the following documents MUST be submitted with this application:
- Listing of any additional locations: Service/Payment Address, Phone, Fax, Email
- Face-sheet of Group Practice’s insurance certificate
- W9 form reflecting payment address
- Provider Roster of all licensed providers including their full name, NPI #1, and license type
Questions regarding this application should be directed to MHC Provider Relations at email@example.com.