The NIHB grant to fund Health Information Technology Implementation in Indian Country closed in April, 2015. Additional funding for the program is not currently available. The content on this page is provided for background and historical information, only.

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Download Tribal Provider Agreement Form

Downloads:

Tribal Provider Agreement Form (Word Doc)


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

Click on Tribal 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
  • 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.

Inquiries:

Carolyn Angus-Hornbuckle
Deputy Director of Policy, Programs and Advocacy

National Indian Health Board
926 Pennsylvania Avenue, SE
Washington, DC 20003
202.507.4070 Office
202.507.4084 Direct
Email: [email protected]