You are here: Providers > Enrollment > Provider Enrollment Pages > Individual or Group Provider Enrollment (Request Enrollment Package) Page

Individual or Group Provider Enrollment (Request Enrollment Package) Page

You use the Request Enrollment Package page to request a provider enrollment package in the mail.

The Request Enrollment Package page contains the following panels:

 

Application Type Information Fields

Field Description
Application Type

Type of provider enrollment application you are requesting (individual, group, Canadian, or Trading Partner).

Note: If you select Individual or Group, you must provide a Provider Type. If you select Trading Partner, you must provide a Trading Partner Classification.

Tip: If requesting both, you must request each package separately.

 

Address Information Fields

Field Description
Organization Name of the organization requesting enrollment. This field is available when requesting a group application.
Last Name Last name of the person requesting enrollment. This field is available when requesting an individual application.
First Name First name of the person requesting enrollment. This field is available when requesting an individual application.
Middle Initial Middle initial of the person requesting enrollment. This field is available when requesting an individual application.
Title Title of the person requesting enrollment. This field is available when requesting an individual application.
Address Line 1 Physical street address where you want the enrollment package sent to.
Address Line 2 More specific address information.
City City where the package is requested.
State State where the package is requested.
Zip Zip code and extension where the package is requested.
Phone Phone number of the location where the package is requested.
Ext Phone extension of the where the package is requested.
Attn Department or person the package is to be sent to.
Contact Last Name Last name of the location's contact person.
Contact First Name First name of the location's contact person.
Contact Phone Phone number of the contact person.
Ext Extension of the contact person.

 

Version as of 6/30/2015.

Copyright © 2017 Conduent, Inc. All rights reserved. Conduent and Conduent Agile Star are trademarks of Conduent, Inc. and/or its subsidiaries in the United States and/or other countries.