Ancillary Provider

Tikka Attach

Network Operations
Provider Application Request Form

Date:

Provider Name:

Specialty:

Group Name:
(If applicable)

Tax Identification Number (TIN):

National Provider Identifier (NPI):

Provider Address:

Telephone Number:

County:

Hospital Affiliations:

Contact Person/Office Manager:

Ambulatory Surgi-Center Affiliations:

Are you participating with Horizon HMO?

Are there other providers practicing at your location?
If yes, please include their names and specialty below:

Please fax or mail to: Horizon NJ Health
Attention: Professional Relations Department
210 Silvia Street
West Trenton, NJ 08628
Telephone: 800-682-9094 Fax: 609-583-3004

Provider Name Specialty

Yes Noq q

Yes Noq q


Date:
Provider Name:
Specialty:
Group Name:
Tax Identification Number TIN:
National Provider Identifier NPI:
Provider Address 1:
Provider Address 2:
Telephone Number 1:
Telephone Number 2:
Hospital Affiliations:
Ambulatory SurgiCenter Affiliations:
Contact PersonOffice Manager:
Provider Name 1:
Provider Name 2:
Provider Name 3:
Provider Name 4:
Specialty 1:
Specialty 2:
Specialty 3:
Specialty 4:
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