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Workers’ Compensation, Auto Injury or First Health Request

Please complete this form to join the Coventry Workers’ Compensation, Coventry Auto Injury or First Health network.  

If you already work with us and need to update your Tax ID (TIN), don’t use this form. Instead, log in to Availity or the electronic transaction vendor that you use.

Log in to our Provider Portal

If you need more information about our application and credentialing process, use the link below. You also will find information on the Council for Affordable Quality Healthcare's (CAQH's) ProView® and ProviderSource™ (for Washington State licensed practitioners). 

Information about application and credentialing process

As a practitioner, you have the right to correct any information obtained during the credentialing process by working directly with the reporting entities. 

All fields marked with a RED asterisk (*) are required.

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Information

1) Practitioner Information

Incorrect date of birth will delay the application request process

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An incorrect tax ID number will delay the application process. Please do not include spaces or dashes. If joining a participating group, please use the group’s tax ID number to link your request with the participating group.

Physicians select your specialty. All others select your provider type. If your specialty/provider type is not listed please call 1-800-353-1232

Degree acronym definitions 

*Applying as

This ID must be 8 numbers.

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Service Location And Mailing Address

2) Primary Service Location And Mailing Address

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National Provider Identifier (NPI) Information

3) National Provider Identifier (NPI) information

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A 10 digit type 1/individual NPI number must be entered if you are a physician (MD/DO).

4) Contract Network Selection

Is the NPI contact person also the contact for contracting?
Are you interested in joining the Coventry Workers' Compensation Network?
Are you interested in joining the Coventry Auto Injury Network?
Are you interested in joining the First Health® Network?
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Further Details

5) Hospital Affiliations

*Do you agree to the Email Acknowledgement?
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