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.

 

Provider Information

 
 
 
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NPI Type?

 Type 1 (individual)     Type 2 (organization)
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Pay To Information

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Physical Location Information

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Mailing Address (If different than Pay To or Physical Location Information)

 
 
 
 
 
 
 

Other Physical Location Information

 
 
 
 
 
 
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Contact Information

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Documentation

We require a W-9 to ensure that we have accurate IRS reporting information. Please attach a 1MB or smaller copy of your W-9 to submit your request. Without a W-9, we cannot process your request. Thank you.
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