Provider Enrollment Form

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Name*
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Title*
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Organization*
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Email Address*
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Date*
MM slash DD slash YYYY
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Company*
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Tanent Key*
Please complete the following steps in order to enroll your practice.

Practice Information *Required Field
Legal Business Name*
Organization Tax ID*
Organization NPI*
Organization Address*
Street Address Line 1*
Street Address Line
City*
Zip*
Organization Phone #*
Organization Fax #*
Point of Contact Details*
Full Name*
Email*
Phone #*

Physician Information *Required Field

Complete the following for each of your physicians within your practice.

Physicians*

Physician Full Name	Physician NPI	Physician Date of Birth	Physician Email

Add Another Physician

Benefit Manager Credentials
Please provide your Administrator's contact information for Avalon, Optum and UnitedHealthcare web portal access.
If you are currently using the UHC (Optum) portal or if you need to designate one, provide the following information:

https://identity.onehealthcareid.com/app/index.html#/login
Optum Administrator Name
Optum Administrator Email
Optum Administrator Phone #
If you are currently using the NIA portal or if you need to designate one, provide the following information:

https://www.radmd.com/RadMD/Common/Login.aspx
NIA Administrator Name
NIA Administrator Email
NIA Administrator Phone #
If you are currently using the AIM portal or if you need to designate one, provide the following information:

https://www.providerportal.com/Default.aspx
AIM Administrator Name
AIM Administrator Email
AIM Administrator Phone #
If you are currently using the Avalon portal or if you need to designate one, provide the following information:

https://avalonhcs.okta.com/login/
Avalon Administrator Name
Avalon Administrator Email
Avalon Administrator Phone #

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Provider Enrollment

Provider Enrollment Form

Please complete the following steps in order to enroll your practice.

Please complete the following steps in order to enroll your practice.

Practice Information *Required Field

Physician Information *Required Field

Complete the following for each of your physicians within your practice.

Benefit Manager Credentials

Please provide your Administrator's contact information for Avalon, Optum and UnitedHealthcare web portal access.

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