​​​​ Non-Participating Provider Registration Form

​Contact PDMsupport@sentara.com if you need assistance or have any questions. Processing the electronic form can take 5 days.

​​Submitter Information

Requestor Name **		Requestor Email **
Group Name **	Group Tax ID **	Group NPI **
Billing / Remit Address **
City **	State * Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) Washington, DC (DC) West Virginia (WV) Wisconsin (WI) Wyoming (WY) Other	Zip **

Enter your 1099 address below (if different)

1099 Address *
1099 City *	1099 State Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) Washington, DC (DC) West Virginia (WV) Wisconsin (WI) Wyoming (WY) Other	1099 Zip *
AssocList *

OPTIONAL Provider Details: Please add complete details for providers associated with group (Up to 5)

Provider Name 1 *	Specialty 1 *	Provider NPI 1 *	Taxonomy 1 *
Provider Name 2 *	Specialty 2 *	Provider NPI 2 *	Taxonomy 2 *
Provider Name 3 *	Specialty 3 *	Provider NPI 3 *	Taxonomy 3 *
Provider Name 4 *	Specialty 4 *	Provider NPI 4 *	Taxonomy4 *
Provider Name 5 *	Specialty 5 *	Provider NPI 5 *	Taxonomy 5 *

Attach your W-9 formYou can upload a maximum of 1 file, up to 90MB.

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