Get Provider Locator Agreement

This guide provides step-by-step instructions on how to complete the Provider Locator Agreement online. Following these instructions will help ensure that your application is accurate and complete.

Follow the steps to successfully fill out the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing your primary facility information. Specify whether it is an inpatient or outpatient facility by selecting the appropriate options. Fill in the name, phone number, and address of the primary practice or facility.
3. Provide details about the -related services offered at your facility by checking all applicable boxes. Include the hours when the site is available for providing injections.
4. Indicate if your facility treats alcohol dependence, opioid dependence, or both. Also, confirm if you are accepting new patients for treatment.
5. List the accepted insurance types by selecting the most appropriate option regarding your practice's insurance policy.
6. Fill out the primary provider's information, including their name and any secondary facility details if applicable. Confirm if there are any secondary providers and provide their information.
7. Carefully read and sign the agreement at the bottom of the form. Ensure you enter your name, title, and the date of signature.
8. After completing the form, you can save changes, download the document, print it, or share it as needed.

Complete your Provider Locator Agreement online today to ensure your services are accessible to those in need.