New Practitioner Billing Form - Practitioner Onboarding

New Practitioner Billing Form (NPBF)

For questions regarding NPBF, please contact Leilani Johnson at (352) 265-7987 or ljoh0003@shands.ufl.edu. A secondary NPBF contact is Managed Care at caremgd@shands.ufl.edu.

Practitioner Information

Today' Date

Date

Practitioner Name (full name as listed on Medical License or Social Security Card)

First Name

Middle Name

Last Name

Practitioner Credentials (MD, DO, CRNA, ARPN, PA-C, etc.)

Department Information

The following areas are available for the contact to select if their provider is not part of the Florida Clinical Practice Association under a UF College of Medicine department: Central Florida Health, Eagle Telemedicine, First Coast Heart & Vascular, St. Johns/Flagler Hospital, TeamHealth/Leesburg Regional Medical Center, Archer Family Health Care, Clinical and Health Psychology, Hospital Dental Service, and Shands (Registered Dietitian, Audiologist). Please contact Leilani Johnson at ljoh0003@shands.ufl.edu/Leilani.Johnson@ufhealth.org if you believe your area is missing.

Department Contact

Department Contact's Email

Department Phone

Primary Office Site Information

Primary Office Site NPBF Information

Primary Office Site Number and Name

Reference the UF Faculty Practice Sites Document below to locate 6-digit Site Number and Name:

UF Health Office Sites and Numbers

Age Range Other

Primary Office Work Schedule

Add More Day(s) & Hours Working at this primary Location?

Yes

Please describe any other day(s)/hours at this primary location

Add Another Office Site?

Yes

Office #2 Site Information

Office #2 Site NPBF Information

Office #2 Site Number and Name

Reference the UF Faculty Practice Sites Document below to locate 6-digit Site Number and Name:

6-Digit Office Site Number (.pdf)

Age Range Other

Office #2 Work Schedule

Add More Day(s) & Hours Working at this primary Location?

Yes

Please describe any other day(s)/hours at this primary location

Add A Third Office Site?*

Yes

Office #3 Site Information

Office #3 Site NPBF Information

Office #3 Site Number and Name

Reference the UF Faculty Practice Sites Document below to locate 6-digit Site Number and Name:

UF Health Office Sites and Numbers

Age Range Other

Office #3 Work Schedule

Add More Day(s) & Hours Working at this primary Location?

Yes

Please describe any other day(s)/hours at this primary location

Add A Fourth Office Site?

Yes

Office #4 Site Information

Office #4 Site NPBF Information

Office #4 Site Number and Name

Reference the UF Faculty Practice Sites Document below to locate 6-digit Site Number and Name:

UF Health Office Sites and Numbers

Age Range Other

Office #4 Work Schedule

Add More Day(s) & Hours Working at this primary Location?

Yes

Please describe any other day(s)/hours at this primary location