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Notes:
Individual Providers need to request an Individual Contract before sending in an application.
Providers submitting application forms must also send the following documents:
- Current New York State License with signature
- Current Federal DEA Registration
- W-9 Form for each billing location
- Copy of Board Certification or Three letters of professional reference
- Professional Liability Insurance Fact Sheet
- Hospital Privilege Letter
- Enrollment is not complete without a signed contract. Please contact Atlantis at 212.747.8257 to have a contract sent to you.
Attn: Provider Relations Department
Atlantis Health Plan
39 Broadway, Suite 1240
New York, NY 10006
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Provider Application Form | |
Health Insurance Claim Form (HCFA 1500) |
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W9 | |
New Provider Location Add-On Form |
