Ancillary Provider
Tikka Attach
Network Operations
Provider Application Request Form
Date:
Provider Name:
Specialty:
Group Name:
(If applicable)
Tax Identification Number (TIN):
National Provider Identifier (NPI):
Provider Address:
Telephone Number:
County:
Hospital Affiliations:
Contact Person/Office Manager:
Ambulatory Surgi-Center Affiliations:
Are you participating with Horizon HMO?
Are there other providers practicing at your location?
If yes, please include their names and specialty below:
Please fax or mail to: Horizon NJ Health
Attention: Professional Relations Department
210 Silvia Street
West Trenton, NJ 08628
Telephone: 800-682-9094 Fax: 609-583-3004
Provider Name Specialty
Yes Noq q
Yes Noq q
Date:
Provider Name:
Specialty:
Group Name:
Tax Identification Number TIN:
National Provider Identifier NPI:
Provider Address 1:
Provider Address 2:
Telephone Number 1:
Telephone Number 2:
Hospital Affiliations:
Ambulatory SurgiCenter Affiliations:
Contact PersonOffice Manager:
Provider Name 1:
Provider Name 2:
Provider Name 3:
Provider Name 4:
Specialty 1:
Specialty 2:
Specialty 3:
Specialty 4:
Screen1:
Screen2: