Provider Email Address Collection

Seeking Email Addresses

In an effort to improve the quality, relevance, and timeliness of provider communications, Trillium Community Health Plan is conducting an audit of our provider contact information, paying special attention to email addresses.

Please complete the form below. You may submit as many contacts as are appropriate for your practice; Up to five (5) email addresses may be included on each submission.

Thank you for helping us to be more nimble and responsive to our providers’ needs.

Practice Name *

Contact Name *

Job Title

Phone Number

Email Address *

Additional Email Address

Preferred Mailing Address *

Physical Address (if different from Mailing Address)

Group NPI

TIN

Provider Type * PCP Specialist Behavioral Health

What is Specialty? *

Line of Business (Check all that apply) * Oregon Health Plan (OHP)/Medicaid

Do you also accept Health Net commercial or Medicare Advantage plans? * Yes No