Get started with CareScout's Provider Program

Please submit the provider enrollment card below. If you are already enrolled in CareScout’s Provider Program and have a question, please email info@carescout.com.

* Indicates a required field
*First Name:		*Last Name:
Agent/Facility Name:
Tax ID/SSN:		Confirm Tax ID/SSN:
*Physical Address One:		Physical Address Two:
*City:		*State:
*Zip:		*Email Address:
*Phone Number:		Fax Number:
Mailing Address1:		Mailing Address2:
City:		State:
Zip:
*Please indicate which Provider Programs you are interested in joining:

*Please indicate your organization type:











Comments/Questions:

Attn: CareScout Provider Program

CareScout

60 Hickory Drive, 4th Floor

Waltham, MA 02451