Note: Providers submitting application forms must also send the following documents:

• Current New York State License with signature
• Current Federal DEA Registration
• W-9 Form for each practice location
• Copy of Board Certification or Three letters of professional reference
• Professional Liability Insurance Fact Sheet

Attn: Provider Relations Department
Atlantis Health Plan
39 Broadway Suite 1240
New York, NY 10006

	Provider Application Form		Health Insurance Claim Form (HCFA 1500)
	W9		New Provider Location Add-On Form