Carelon Behavioral Health Provider Data Sheet

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1. PROVIDER INFORMATION

A. DEMOGRAPHIC INFORMATION
Last Name*	First Name*	MI	Gender
			Female Male
			Unknown
Mailing Address Line 1*	Mailing Address Line 2

City*	County	State*	Zip*

Fax: (include area code)*	Telephone:(include area code)*
Ext:	Ext:
Mobile Phone	Pager

Social Security Number*	Date of Birth*	Professional Designation or Title*

Indicate any other name you may be have used in the past(e.g., maiden name, etc.)		Internet E-mail address*


Carelon Behavioral Health, Inc. is engaging in an automated approach to managing and maintaining your network Provider file information. As a network Provider this automated system will immediately update any change you submit regarding your practice and billing activities (i.e. address/phone number changes) and will automatically notify you of our need for you to submit updated license renewals and malpractice information.
To take advantage of this paperless and automated system, indicate your preferred method of communication, including the day and the time that is most convenient.

B. COMMUNICATION PREFERENCE: Please select your preferred method of communication. If you only have one preferred method, please indicate N/A on the other method.


Primary Communication Preference:
Secondary Communication Preference:

DAY/TIME PREFERENCE (check only one for each category)