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Providers > Provider Forms

Note: 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 practice location
  • Copy of Board Certification or Three letters of professional reference
  • Professional Liability Insurance Fact Sheet
Please send completed applications to:
Attn: Provider Relations Department
Atlantis Health Plan
39 Broadway Suite 1240
New York, NY 10006
Provider Application Form Health Insurance Claim Form (HCFA 1500)
W9 New Provider Location Add-On Form