AFSPA – Caring For Your Health Worldwide

Please fill in all mandatory fields marked with an asterisk (*).

Section I - Provider or Facility

Legal Name: *

Commercial Name: *

Address: *

Provider Type: *

Multiple Locations: *

Yes No

If yes, please provide a separate locations list including Facility names, addresses, phone numbers, administrative and billing contact.

Please upload files in PDF format.

Billing Point of Contact Full Name: *

Billing Point of Contact Full Address: *

Billing Point of Contact Title: *

Billing Point of Contact Email Address: *

Billing Point of Contact Phone Number: *

Administrative Point of Contact Full Name: *

Administrative Point of Contact Full Address: *

Administrative Point of Contact Title: *

Administrative Point of Contact

Email Address: *

Administrative Point of Contact Phone Number: *

Section II - Services and Specialties

Inpatient Hospital: *

Yes No

Accidental Injury: *

Yes No

Complete Maternity Care: *

Yes No

Preventive Care: *

Yes No

If yes, please provide a separate document with the preventive care services list or packages, and prices.

Surgery: *

Yes No

X-ray/Imaging: *

Yes No

Lab: *

Yes No

Physical, Occupational,

Speech Therapy: *

Yes No

Home Health Services: *

Yes No

Mental Health Services: *

Yes No

ABA Services: *

Yes No

Other Services:

Section III - Electronic Funds Transfer (EFT) and Claims

EFT Reimbursement Currency: *

Does your facility provide discounts to members or insurances for services rendered? *

Yes No

Itemized Bill or Invoice Sample *

Attach a bill or invoice in PDF format as a separate attachment with the following information: member’s name, date of birth, and address; member’s ID number; provider’s full name and address; dates of services or supplies furnished; diagnosis/reason for visit; type of each service or supply; charge for each service or supply; and HIPAA-compliant platform used for telemedicine services.

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