Specialty

Business/Group Name

TIN/EIN

Group NPI

Address 1

Address 2

City

County

State

Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Fax

( ) -

Are you a current TRICARE Network Provider?

Yes No

Contact Information

Name

Email

Phone

( ) - Extension

Credentialing Contact Information

Name

Email

Are you currently a participating group in Humana Behavioral Health’s Commercial, Medicare Advantage, EAP, and/or Healthcare Exchange network(s)?

Yes No

Are you interested in joining Humana Behavioral Health’s other networks, in addition to TRICARE?

Yes No

Are you considered a physician group for a specific Facility or Hospital?

Yes No

Facility/Hospital Name

Facility/Hospital TIN

Are you affiliated with an independent practice association (IPA), physician-hospital organization (PHO), or management services organization (MSO)?

Yes No

IPA/PHO/MSO Name

IPA/PHO/MSO Contact/Email

Are you currently providing Telemental Health (TMH) services?

Yes No

Do you have the capacity to provide Telemental Health services?

Yes No

Do you accept Medicare patients?

Yes No

Areas of Expertise

So that we can make the most appropriate referrals for care, please check the specialties listed below that best represent your area(s) of expertise:

Submit