Provider Program Inquiry

Before you submit this enrollment card, please read through the description of all available provider programs so that you can select the programs that may be appropriate for your company.

Please submit the form below to tell us more about your business. A CareScout representative will respond with enrollment information as soon as possible.

Current Providers Enter Provider Number :
Forgot your provider number? Email CareScout at providerprogram@carescout.com for assistance

* Required Fields
*First Name:		*Last Name:
*Business Title:		*Organization:
*Address One:		Address Two:
*City:		*State:
*Zip/Postal Code:		*Main Phone Number:
Best Phone number to contact you:		Main Fax Number:
*Your Email Address:		Company Website Address:
*Organization Type:

*Is your business part of a larger organization?

If part of larger organization, please identify the parent organization name:
Parent Organization Name:
*Do you accept any of the following forms of payment?
Private Pay Long Term Care Insurance Health Insurance Medicare Medicaid Veteran's Benefits Worker's Compensation Other
*Please tell us which provider programs you want to enroll in:

Comments/Questions:

Attn: CareScout Provider Program

CareScout

230 Third Avenue, Second Floor

Waltham, MA 02451