Presbyterian

Providers

Contracting Form

Presbyterian continually looks to create new partnerships that ensure members have access to needed services throughout New Mexico. We offer Medicare Advantage, Medicaid, and Commercial plans. If you are a group, facility, or an individual provider, please complete the following form to begin the contracting process. We look forward to partnering with you to keep New Mexicans healthy.​

* = indicates required fields

Products of Interest*

Note: To choose Commercial, providers must also choose a government program (Medicaid or Medicare)



Practice Details


If you are filling this out for yourself and you are an individual provider, please list your name, date of birth and gender. If you are filling this out as a group or facility, please skip to the National Provider Identifier Number (NPI) field.


Find out more about NPI

If not applicable, please put "NA"
If not applicable, please put "NA"
(located on your NPI application)
Note: primary care providers are required to have an open panel for all contracted lines of business to be admitted to the network
(e.g., pediatrics – max. age 18; internal medicine – min. age 40; geriatric – min. age 50; OB/GYN – dependent on the provider)

Contact Information

Physical Address

Current Mailing Address

Billing Address

Other Practice Location


Practice Associates (Facilities do not need to complete a roster)

If your practice has more than five providers, please attach a roster with all information at the end of the form.

Practice Associate

(located on your NPI application)

Practice Associate

(located on your NPI application)

Practice Associate

(located on your NPI application)

Practice Associate

(located on your NPI application)

Practice Associate

(located on your NPI application)

Add Practice Associate



Please upload all supporting documents including: Proof of Good Standing with Federal and State Regulatory Bodies.

  • State Operator's License and Expiration Date
  • Accreditation Documentation
  • W-9
  • Ownership and Controlling Interest Form (located on phs.org)
  • Malpractice Insurance Certificate
  • State Pharmacy Registration and/or Controlled Substance Registration
  • DEA Certificate

If necessary, please fax remaining documents to 505-923-5440.

Attach Supporting Documentation

Total size of all files should not exceed 4MB.
Allowed file types: .doc, .docx, .rtf, .xls, .xlsx, .pdf, .png, .jpg, .jpeg, .gif











Add Another File