Attention:

Please review the guide below to determine the most efficient process for communicating provider information to HealthPartners.

https://www.healthpartners.com/provider-public/forms/contracting.html

Add a New Site Location Request Form

-Instructions-

Use this form to add a physical location to an existing HealthPartners-contracted provider group

Do not use this form to request a contract with HealthPartners

This form is specific to HealthPartners contracted medical providers only

Complete a separate form for each new physical location being added

A request to add a new site to an existing, active HealthPartners contract is not a guarantee that the site will be added

Please allow up to 60 days for the completion of the new site addition review process

Send the form in an editable electronic format. Scanned handwritten or faxed copies are not accepted.

Email the completed form as an attachment to your Service Specialist or to ProviderContracting@HealthPartners.com.

Add a New Site Location Request Form

Provider Representative’s Information
Today’s Date
Name
Email & Phone

Contract Entity Information
Legal name as reported on W-9
Marketing/DBA name
Tax ID
Administrative Street Address
City, State, Zip Code
New Site Information
Effective Date
Specialty
Legal name
Marketing name
Site Tax ID
Physical Street Address
City, State, Zip Code
Mailing Address
City, State, Zip Code
Referral Auth Address
City, State, Zip Code
Appointment Phone
Fax
CLIA #
Medicare Certification Number
Appointment Hours	Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
New Site Billing/Remit Information
Billing NPI
Payment NPI
NPI Type (i.e. Hospital, Home Care, DME.)
Remit/Pay To Name
Remit Street Address (where checks should be sent)
Remit City, State, Zip Code
Remit Office Phone
Remit Office Fax
Claim form (1450 or 1500)

Add a New Site Location Request Form (continued)

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For the site’s practitioner list, complete this grid and send to us in an editable electronic format or submit an excel spreadsheet with the same header columns as below. This is not a credentialing application. If a practitioner is new and not active in the HealthPartners system, you will need to follow HealthPartners Credentialing enrollment process.

Practitioner List for New Site
Last Name	First Name	MI	Birthdate	Prof Suffix	License #	Type 1 NPI	Practicing Specialty	Primary Site? (Y/N)	Suppress? (Y/N)