Facility Information Form

P.O. Box 327 Attn: Provider Relations Seattle, WA 98111 Fax: 425-918-4249 Phone: 800-596-3382, option 4

Use this form to provide demographic information about your facility.

Complete the entire form and attach a copy of your W9. Indicate N/A in those fields that don’t apply. This form is for informational purposes only; it is not a contract or guarantee of participation under LifeWise Health Plan of Oregon® plans.

Business Name: NPI #: NOTE: If more than one location, please attach additional sheet(s) for each location. Location Address: City, State, Zip: Business Phone: Fax #: Servicing Counties Facility Specialty/Type: Web URL: Remit Address (pay to) Same as Location Address Yes No (If no, please complete information below) Make Check Payable to: Remittance Address: City, State, Zip: Billing Phone: Fax #: Mailing Address (correspondence/contracts) Same as Location Address Yes No (If no, please complete information below) Attn: Mailing Address: City, State, Zip: Phone:

NOTE: Federal Tax Identification Number (TIN) and legal entity name must be listed exactly as recorded with the IRS. The Federal TIN is used by the provider for claims submission to LifeWise. Federal TIN: (Attach IRS Form W-9) IRS Legal Entity Name: Additional Comments:

Signature of person completing this form Date Phone

Please return this form to LifeWise when completed.

016119 (03-2017)