Reimbursement > Therapist Registration

Please complete the form below to apply for an attending provider number with the Alamance-Caswell-Rockingham LME. Once completed, save the form to your local drive and email it to Teresa Arrwood. The form can also be printed, completed, and faxed to 336-513-4379 to the attention of Teresa Arrwood.

If licensed, you must include your Medicaid Direct Enrolled Provider Number (DEP) and National Provider Number (NPI). We cannot assign a number without these. If you provide services at multiple locations within your organization and are required to bill those services through ACR LME, please complete a separate form for each location indicating the appropriate NPI for each.

All zip codes must be zip+4. If you are not sure of your +4 extension, please visit the US Postal Service website (www.usps.com) and use the zip+4 tool available to determine the correct extension.

If you have any questions or difficulty completing this form, contact Teresa Arrwood at 336 513-4200 ext. 4415.

Therapist Registration Form