Northwest Portland Area Indian Health Board: Indian Leadership for Indian Health

Application Forms

Download National REC I/U Provider Agreement Form

How to fill out Provider Agreement Form (word doc) and send in an E-mail
Click on the I/U Provider Agreement Form (Word Doc) below:
I/U Provider Agreement Form (Word Doc)

  • Fill out form
    • Note: in Practice Details section you have a drop down box for (Practice Type)
    Note: in Providers Information section you have a drop down box in (type of Providers)
  • Click save
    • Save form to your desktop
    Use Unique Identifier for the name of form
    i.e. (yourfacilityname) then click save
  • E-mail to NPAIHB Regional REC
    • Attach provider agreement form and e-mail
    Send to
  • Or fax with cover
    • From: facility name and address including main phone number
    Fax to NPAIHB Regional REC 503-228-8182

    If you’re having trouble downloading or faxing in the Provider Agreement Form please contact me I will provide a word.doc directly to your email or fax. Thank you.

    Contact info:
    Katie Johnson, Pharm D
    LCDR, USPHS
    Northwest Portland Area Indian Health Board
    Project Director, NPAIHB Regional Extension Center

    503-416-3272

    Download Tribal Provider Agreement Form

    How to fill out the Tribal Provider Agreement Form (word doc) and send in an E-mail
    Click on the Tribal Provider Provider Agreement Form (Word Doc) below:
    Tribal Provider Agreement Form (Word Doc)

  • Fill out form
    • Note: in Practice Details section you have a drop down box for (Practice Type)
    Note: in Providers Information section you have a drop down box in (type of Providers)
  • Click save
    • Save form to your desktop
    Use Unique Identifier for the name of form
    i.e. (yourfacilityname) then click save
  • E-mail to NPAIHB Regional REC
    • Attach provider agreement form and e-mail
    Send to
  • Or fax with cover
    • From: facility name and address including main phone number
    Fax to NPAIHB Regional REC:  503-228-8182

    If you’re having trouble downloading or faxing in the Provider Agreement Form please contact me I will provide a word.doc directly to your email or fax. Thank you.
    Contact info:
    Katie Johnson, Pharm D
    LCDR, USPHS
    Northwest Portland Area Indian Health Board
    Project Director, NPAIHB Regional Extension Center

    503-416-3272