Order Form
 

Use this page to request information from PTPN. Information requested will be forwarded to you within 3 business days of the request. If information is unavailable or clarification is needed, you will be contacted.

Please provide the following contact information: (* denotes a required field)

First Name *  
Last Name * 
Title * 
Organization * 
Address 1 * 
Address 2 
City*     
State *
Zip *
Phone * 
Fax 
Email * 
Web site 

Choose which of the following information you are requesting:

Information on becoming a PTPN member
Information on contracting with PTPN nationally
Information on contracting with PTPN in my State
New Therapist Credentialing Form
Master Contract Details and Payer List (PTPN Members only)
PQRI Information (PTPN Members only)
PTPN Documentation Forms (PTPN Members only)
PTPN Member List (PTPN Member and Contractors only) for the geographic areas specified below
Resource Sheet from Credentialing Site Visit (specify which sheet below)
How to Identify and Bill for PTPN Patients:
A Multimedia Training Presentation
(on CD, available to PTPN members only)
Other - please specify below

 

Please use the box below to request information that is not listed above.