Get Provider Locator Agreement

Filling out the Provider Locator Agreement online is a straightforward process that allows healthcare providers to offer their services to patients in need. This guide provides step-by-step instructions for completing the form accurately and efficiently.

Follow the steps to complete your Provider Locator Agreement form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor. This step will give you access to the agreement, allowing you to review and fill out the necessary information.
2. Provide your personal information, including your name, address, and contact details. Ensure that all information is accurate and up-to-date as it will be used for verification and communication.
3. Select your primary facility type. You will need to check the appropriate box that describes the nature of your facility, whether it is inpatient or outpatient.
4. Fill in the name of your primary practice or facility, along with the phone number, fax number, and address. This information helps maintain clear communication with you and your facility.
5. List additional relevant information including your facility's website, DEA number, NPI number, and ME number. Providing these details ensures proper registration and verification for your services.
6. Indicate the services offered related to by checking all applicable boxes. This allows users to understand the range of services you provide.
7. Specify the hours your site is available for providing injections. This information is essential for scheduling and patient referrals.
8. Confirm your experience injecting and declare whether your facility treats alcohol and/or opioid dependence. Providing truthful answers is crucial for eligibility in the program.
9. Complete the section for the primary provider by filling in their name. Answer the questions about secondary facilities and providers as applicable.
10. Review the terms of participation. By signing, you certify that you have read, understood, and agree to comply with these terms. Ensure your name, title, and signature are clearly printed.
11. Once all steps have been completed, save your changes, download the form, print it for your records, or share it as necessary. Make sure to return the completed form to the Touchpoints Support Services as instructed.

Take the next step and fill out your Provider Locator Agreement online today.