SOLE PROPRIETORS:

If you will be receiving payments made directly to you from TennCare for Medicare Cross-Over claims or you are participating in the EHR Incentive Payments Program, you must complete Required Forms shown above.

Personal Information
* First Name
Middle Name
* Last Name
Suffix
* Birth Date
* SSN
Professional Identification
* Provider Type
* Primary Practice State
* Provider NPI
* State License
* License State
DEA
UPIN
 
Credentialing Contact Information
* Address
Address 2
* City
* State
* Zip (First 5)
Ext Zip (Last 4)
* Phone No
Phone Extension
 
* E-mail
* Confirm E-mail