NPI Provider Registration Forms

Participating Provider Registration Forms

If you would like to be a participating provider, please submit a Provider Participation Form to start the credentialing process.

Nonparticipating Provider Registration Forms

If you are a nonparticipating provider and need to register your NPI with Independence, select the appropriate NPI registration form below. Complete the form and submit it along with a copy of your NPI confirmation and a completed W-9 form.

Nonparticipating Provider NPI Registration Form Type Link to Appropriate Registration Form
Professional Providers (e.g., PCPs, specialists) Nonpar Professional Registration Form
Facility/Ancillary Providers (e.g., hospitals, rehabs, DME, ambulance) Nonpar Facility/Ancillary Registration Form