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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), do not use this form. Instead, log in to NaviNet or the electronic transaction vendor that you use.

Log in to NaviNet 

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) Information

Incorrect date of birth will delay the application request process

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Please enter the email address of the individual authorized to sign the agreement

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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.
An incorrect tax ID number will delay the application process.

If your Specialty is not listed please call 1-800-353-1232

*Applying as
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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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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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