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Before Health Plan of Nevada and Sierra Health and Life can add the following provider to your group, the following form must be
completed in full. The provider must hold a valid license in the state of their primary location.
* Indicates a required field
If either option is selected, you must download and complete this form and attach it with your online submission.
If you are not enrolled in CAQH, download enrollment instructions here.
* Providers who perform surgeries on an outpatient basis are required to have privileges at a plan contracted Ambulatory Surgery Center.
If the information submitted on this application is false, inaccurate, inappropriate or incomplete, the application will be withdrawn or will not be considered for enrollment in the network.