web
You’re offline. This is a read only version of the page.
close
Provider Network Solutions
Sign In

Provider CRF Request

Step 1 of 7

Start your CRF Request

Enter your NPI and email to begin your request.

NPI Number *
Email *

Billing Provider - Identification

Legal Name
Billing NPI Number
Doing Business As
Billing Email

Rendering Provider - Identification

Rendering NPI Number
10 digits - will be validated against NPPES
Legal Name (from NPPES)
Doing Business As (from NPPES)
Rendering Email

Existing Lines of Business

These are the current lines of business for the Billing Provider (read-only).

Line of Business Patient Population
Loading...

Line of Business & Patient Population

Select ONE line of business for this request.

Line of Business
Patient Population

Financial - Billing Provider

Only Federal Tax ID / SSN is required. Other fields are optional.

Federal Tax ID / SSN
Payee Name
Bank Account Type
Account Number
Routing Number

Financial - Rendering Provider

Only Federal Tax ID / SSN is required.

Federal Tax ID / SSN

Existing Specialties - Billing Provider

Current specialties for the Billing Provider (read-only).

Line of Business Specialty License Number
Loading...

New Specialties - Billing Provider

Add Specialty

Add new specialties for this request (optional).

Specialty License Number Actions
No new specialties added (optional)

Provider Details - Billing

Date of Birth (yyyy-mm-dd)
Provider Email
Do you provide telemedicine service?
Have you completed cultural competency training?

Specialties - Rendering Provider

Add Specialty

At least ONE specialty is required.

Specialty License Number Actions
No specialties added

Provider Details - Rendering

Date of Birth (yyyy-mm-dd)
Provider Email
Do you provide telemedicine service?
Have you completed cultural competency training?

Existing Locations - Billing Provider

Current addresses for the Billing Provider (read-only).

Type Address Phone Primary Accept New PEP
Loading...

New Locations - Billing Provider

Add Address

Add new addresses for this request (optional).

Type Address Phone Office Hours Actions
No new addresses added (optional)

Locations - Rendering Provider

Add Address

At least ONE address is required for Rendering Provider.

Type Address Phone Office Hours Actions
No addresses added

Review & Signature

Authorized Official Name *
This is the name of the provider's Authorized Official (the person authorized to sign this request). It must not match the Billing Provider's name, unless they are the same person.

Signature

Please sign inside the box to authorize your CRF submission. Use your mouse (desktop) or your finger (mobile). Click Clear to restart and Submit to save.