Rehab Provider Network Facility Application

Facility Application

1. FACILITY INFORMATION

Facility Legal Name

Business Name (if different from above)

Federal TIN

Practice Owner's Name

Practice Owner's Title

Email Address

Phone Number

2. Please upload W-9 form.

3. Type of Organization:

4. State in which organization is registered:

5. Practice setting:

Free Standing
Hospital-Based Outpatient
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.