Download National REC I/U Provider Agreement Form

Downloads:

I/U Provider Agreement Form (Word Doc)

How to fill out Provider Agreement Form (word doc) and send in an E-mail

• Fill out form
  • Note: in Practice Details section you have a drop down box for  (Practice Type)
  • Note: in Providers Information  section you have a drop down box in (type of Providers)
• Click  save
  • Save form to your desktop
  • Use  Unique Identifier for the name of form
    • i.e. (yourfacilityname)
    • then click save
• E-mail to NIHB National REC
  • Attach provider agreement form and  e-mail
  • Send to tflood@nihb.org
• Or fax with cover
  • From: facility name and address including main phone number
  • Fax to NIHB national REC:  202-507-4071

If you’re having trouble downloading or faxing in the Provider Agreement Form please contact me  I will provide a word.doc directly to your email or fax. Thank you.

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