What forms do I need?
Disclosure Forms
- Disclosure Form For a Provider Entities
- Disclosure Form For a Provider Person
- Disclosure Form FAQs
- Handling of Ownership & Disclosure Forms
- Providing Social Security Number Law Library
Exclusion Databases
Where should I send my disclosure forms?
| Health Plan | Numbers |
| United Healthcare Par providers: Mail: Network Management UnitedHealthcare 10 Cadillac Drive, Suite 200 Brentwood, TN 37027 Non par providers: Mail: United Healthcare Operations 2035 Lakeside Centre Way, Suite 200 Knoxville, TN 37922 |
Fax: 615-372-3564 Fax: 888-353-7988 |
| BCBST Mail: PNM Compliance One Cameron Hill Circle Ste 0007 Chattanooga, TN 37402 |
Fax: 423-535-3066
or 423-535-5808 |
| Amerigroup |
Fax: 877-423-9973 |
