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

Click on I/U Provider Agreement Form (Word Doc)
  • 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 paf@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.

Jason Heinecke
AI/AN National HITEC REC Director
Office: 202-507-4083
Email: jheinecke@nihb.org