Welcome to the MINES & Associates, P.C.
Online Provider Application
From here, you will be able to complete all of the applicable documents to be considered for our Preferred Provider Organization. Once you have completed all forms, MINES' staff will review your application and contact you via email. This form is acceptable for both individual providers as well as group practices. Please note that if your group does not bill under a single tax ID number, each provider will need to complete their own application including a signed contract for applicable services.
Information you will need to complete this application
- TAX ID Number; Either your SSN or EIN, depending on how you bill for services
- NPI Number; Must match your name or organization name. If you do not currently have an NPI Number, please register for an NPI Number before completing this application
- Liability Information; If you have had any past claims history, you will need to provide explanations for any history pertinent to providing these services as well as information regarding your Professional Liability Insurance including Insurer and Date of Expiration
- Licensure Information
Please refer to instructions (in red) for details regarding information that must be provided on each page.
Additionally, completing this application neither confirms nor guarantees acceptance for the MINES panel and your completion of this contract will not result in immediate addition to our panel. Please allow up to 2 business days to receive confirmation.
If you are associated with a practice that includes an IOP, IP, PHP or Residential Program, please contact a specialist at 303.953.4043.
PLEASE COMPLETE ONE OF THE FOLLOWING TO CONTINUE:
If you practice in one of the following cities, select the city for your appropriate contract:
If your particular city is not listed above, please select the state where you practice: