Mental health and chemical dependency professional contact form

Mental health and chemical dependency professional contact form

Please note: This form is to be used by behavioral health and chemical dependency professionals contact their provider services representative.

Physicians, other professional providers or medical facilities should contact their provider relations representatives & consultants.
Dentists and other dental professionals should contact their dental services representatives.
Vision, chiropractic and other complementary and allied professionals should contact their allied services representative.
Members should contact customer service.

Please complete a Provider Information Update Form when:

A provider leaves or joins your clinic or practice
You have a change to your:

Organization's address
Phone number
Tax identification number
National Provider Identifier number

The results of this form are encrypted and sent to our secure server for your privacy. Your form will be sent directly to your allied services representative. Please allow up to five business days for a response. For a more immediate response, please phone your allied services representative directly.

*Asterisks indicate required fields.

I would like information on the following:
	Reimbursement Policy
	Our issue/problem is:
	Medical Policy
	Our issue/problem is:
	General billing and coding methods relating to:
	(please describe)
	I would like to request a new provider orientation

	Other request (please describe)

*How would you prefer to be contacted?
	Phone
	Email

Your details:
*	Name:
*	Email:
*	Phone number:
*	Office/Practice name:
*	Office/Practice address:
*	Tax ID: