Request to Add a New Health Care Provider Request for New Health Care Provider Form Facility Licensing Agency Type License/File No. Address Phone Email Website Specialty Actions Edit Duplicate Delete Select "Add Provider" below and complete the form to create your first provider. If additional providers need to be added, entries can be edited or duplicated as needed. Once all providers have been added, select "Submit for Consideration" to finalize your submission. Add Provider Maximum number of another provider reached.