Become a participating provider

Use this form to add a new practice or a new provider within a practice.

General information

Credentialing contact

Primary practice information

Tax information

Hours working as a PCP at primary location

Credentialing contact mailing address

New providers

Please note from time to time it may be necessary for our Medical Director or their designee to speak to the provider directly. Please note this information would not be shared outside of BCBSRI. Failing to provide direct contact information may delay the provider's enrollment request.

Additional information

Do you use an electronic medical record in your practice?
Is your practice an NCQA certified Patient Centered Medical Home (PCMH)?
Are you a participating provider in an Accountable Care Organization (ACO)?
Do you operate a concierge style practice which requires your patients to pay a periodic retainer fee for any of your services or do you intend to operate a practice in this manner in the future?
Do you participate as a New England Health Plan PCP in another state?
Will you be perfoming Telemedicine visits?
At what frequency

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