Care Design NY Network Provider Demo Form

Care Design NY Network Provider Demo Form

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Provider Demographic Information
Organization / Agency Name *
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DBA (if applicable)
N/A
Tax ID(s) (if applicable)
N/A
NPI(s) (if applicable)
N/A
DD Agency
N/A
Organizational Type
N/A
Primary Service Address
N/A

Street Address
Address Line 2 City State/Region/Province
Postal / Zip Code

-Select-
Country
Organizational Contacts
Contact Type Descriptions:

Contract Contact: Your organization's CEO, Executive Director, etc. who would be responsible for signing, negotiating or updating contracts or agreements.

Credentialing Contact (if applicable): The individual responsible for overseeing provider credentialing within your organization.

Provider Contact: The individual within your organization who the Provider Relations team may contact for further service type information, outreach and educational events, etc.

Care Manager Contact: The most appropriate contact information to give to a Care Design NY Care Manger in need of your organization's service for an individual they support. This may include the person responsible for intake and referrals, or general organizational contact information if applicable.
Note: the Care Manager Contact information will be made available to all Care Design NY Care Managers through our network search form.
Contract Contact:
Your organization's CEO, Executive Director, etc. who would be responsible for signing, negotiating or updating contracts or agreements.
Contract Contact Name
N/A

First Last
Contract Contact Email
N/A
Contract Contact Phone
N/A
Contract Contact Fax
N/A
Credentialing Contact (if applicable):
The individual responsible for overseeing provider credentialing within your organization.
Credentialing Contact Name
N/A

First Last
Credentialing Contact Email
N/A
Credentialing Contact Phone
N/A
Credentialing Contact Fax
N/A
Provider Contact:
The individual within your organization who the Provider Relations team may contact for further service type information, outreach and educational events, etc.
Provider Contact Name
N/A

First Last
Provider Contact Phone
N/A
Provider Contact Fax
N/A
Care Manager Contact:
The most appropriate contact information to give to a Care Design NY Care Manger in need of your organization's service for an individual they support. This may include the person responsible for intake and referrals, or general organizational contact information if applicable. Note: the Care Manager Contact information will be made available to all Care Design NY Care Managers through our network search form.
Care Manager Contact Name
N/A

First Last
Care Manager Contact Email
N/A
Care Manager Contact Phone
N/A
Care Manager Contact Fax
N/A

Provider Services
Please complete the information below for each service type your organization provides.

Select the + button to add another row for each service type.

Hold the "Ctrl" button to select more than one county or population served for each service provided.
Provider Services
-- No Fields Available --
- Service Type
- Counties Served (select all that apply)
- Population Served (select all that apply)
- License # (if applicable)
- NPI (if applicable)
- Service Type Notes
Add Entry Add Entry
- Service Type
  N/A
- Counties Served (select all that apply)
  N/A
- Population Served (select all that apply)
  N/A
- License # (if applicable)
  N/A
- NPI (if applicable)
  N/A
- Service Type Notes
  N/A
- Service Type
  N/A
  
  -Select-
- Counties Served (select all that apply)
  N/A
- Population Served (select all that apply)
  N/A
- License # (if applicable)
  N/A
- NPI (if applicable)
  N/A
- Service Type Notes
  N/A

Care Design NY Network Provider Demo Form

Provider Demographic Information

Organizational Contacts

Provider Services

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