Provider Enrollment - New - Zotec Partners

Provider Enrollment – 9/3/25

Your Information

Name(Required)

First Last

Email(Required)

Phone

Provider Details

Provider Request Type(Required)

New Provider

Provider Termination

First Name(Required)

Middle Name

Last Name(Required)

Degree

NPI(Required)

Please enter your 10 digit NPI.
If your provider does not yet have an NPI please wait and submit this form when their NPI is available.

Start Date(Required)

Termination Date(Required)

(Last day worked)

Is this provider a Resident?(Required)

Intended Date of Residency Completion(Required)

CAQH User Name

CAQH User Password

Email Address(Required)

Provide an email address that is regularly checked as Zotec will use this to communicate with the provider

Is access to the Physician RFI Portal needed?

What Organization(s) is the Provider joining?(Required)

An organization is considered a single, unique tax ID. Please provide the Name and Tax ID of the group the Provider will be joining.

What Organization(s) is the Provider terming from?(Required)

An organization is considered a single, unique tax ID. Please provide the Name and Tax ID of the group the Provider will be joining.

What locations will the Provider render service?

A location is considered the physical address where services are rendered or where patients are seen.

What locations will the Provider be terming from?(Required)

A location is considered the physical address where services are rendered or where patients are seen.

Does this provider’s termination impact the group's ownership, control, authorized official(s) and/or delegated official(s)? Failure to report changes timely may result in group deactivation with Medicare.

Effective Date of this Change(Required)

Role Terming From(Required)

Please Explain

Does this provider’s addition to the group impact the group's ownership, control, authorized official(s) and/or delegated official(s)? Failure to report changes timely may result in group deactivation with Medicare.

Effective Date of this Change(Required)

Role Adding(Required)

Please Explain

Does the Provider perform teleradiology services?(Required)

Telerad: provider is exclusively reading from a distant site, e.g. home address
Hybrid: provider is reading from a hospital or office location as well as distant site, e.g. home address

Home Address(Required)

*Required if Provider performs teleradiology services

Street Address Address Line 2 City State ZIP Code

URL

This field is for validation purposes and should be left unchanged.