Supporting Documentation for Ancillary Provider Demographic Updates

Specify whether you are closing an existing location and/or adding an additional location.

Documentation required:

1. Communication from provider with signature on company letterhead
2. W-9
3. Americans with Disabilities Act (ADA) survey, if applicable
4. License
5. Malpractice insurance
6. Accreditation or state survey, if applicable
7. Disclosure Statement for Hospital and Ancillary Providers form
8. Ancillary Provider Disclosure Questions form

Documentation required

1. Communication from provider with signature on company letterhead
2. New contact name, phone, fax, email
3. Disclosure Statement for Hospital and Ancillary Providers form

Note whether you are or are not assuming liability of prior tax ID number.

Documentation required:

1. Communication from provider with signature on company letterhead
2. W-9
3. Application
4. License
5. Malpractice insurance
6. Accreditation or state survey, if applicable
7. ADA survey, if applicable
8. Copy of signed agreement
9. Disclosure Statement for Hospital and Ancillary Providers form

Documentation required

1. Communication from provider with signature on company letterhead
2. W-9

Documentation required

1. Communication from provider with signature on company letterhead
2. W-9

• Please note that for Horizon NJ Health providers, the billing address cannot be a PO Box; it must be a physical location.

Documentation required:

1. Communication from provider with signature on company letterhead
2. Valid/active NPI number
3. Specify Horizon BCSNJ or Horizon NJ Health or both

Documentation required:

1. Communication from provider with signature on company letterhead
2. Termination date
3. Termination reason

Documentation required:

• Communication from provider with signature