National Provider Identifier (NPI)
Nonparticipating Professional Provider Registration Form
Please complete this form with as much information as possible. The receipt of accurate, up-to-date information is vital to ensuring successful registration with AmeriHealth New Jersey.
Note: This form is to request set-up in our system as a Non-Par Professional Provider. If you are going to submit claims as a Facility or Ancillary entity, please fill out the Non-Par Facility/Ancillary form.
Incorrect set-up will prevent your claims from paying.