Date:  December 15, 2017  

Provider Enrollment Application


 TennIIS Enrollment Application
Practice Name:
 Address:
Street Address:
Street Address2:
City:
State:
County:
Zip Code:
Phone:
Phone Extension:
Fax:
Office Manager:
Email Address:
 Mailing Address ( if different than above ):
Street Address:
Street Address2:
City:
State:
County:
Zip Code:
Facility Type:  
Facility Type Comments ( if Other ):
 Facility Type
 Does this practice see adults, children, or both?  
 Does this practice provide obstetric care?  
 Does this practice primarily provide inpatient care, outpatient care, or pharmacy services?  
 Select the classification that best describes this Primarily Inpatient practice.  
 Is this a multi-specialty group practice?  
 Select the specialty that best describes this Primarily Outpatient practice.  
 Select the sub-specialty that best describes this Pediatric practice.  
 Select the sub-specialty that best describes this Internal Medicine practice.  
 Select the sub-specialty that best describes this OB/GYN practice.  
 Select the sub-specialty that best describes this Other practice.  
 Has this practice registered for TennIIS access in the past?
         Yes this practice registered for TennIIS access every year.
         Yes this practice has registered in the past but not access TennIIS in over 1 year.
         No this is the first time practice has registered for TennIIS access.
         Don't know
 Current Computer Hardware Setup:
Internet Access Type: