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Join Our Provider Network Form

Provider Recruitment Form

If you are submitting the form (below) as a Medicaid provider, you must have a valid PA Medicaid PROMISe ID.

If you are submitting the form as a Medicare provider, you must have a valid Federal Medicare number and not be listed on the Medicare Opt-Out report.

Please be aware that this form is an inquiry for consideration and not an official registration. We will review your request and if we are in need of your specialty, a representative will contact you to help guide you through our formal application process.

Thank you for your interest in joining Health Partners Plans' provider network!

*Indicates required field

Provider Type *

County

Auxiliary/Supplemental Providers

Applying As *

Group Information

Group Name (as listed on the W-9) *

TIN *

Street Address *

City *

State *

ZIP Code *

Provider Information

Provider Email *

Provider Phone Number *

Provider Fax *

Contracting Contact Information

The Contracting Contact is the individual responsible for signing contracts. The individual named will receive contracts electronically to sign and return to Health Partners Plans.

Contracting Contact First Name *

Contracting Contact Last Name *

Contracting Contact Email *

Contracting Contact Phone Number *

Contracting Contact Fax *

Credentialing Contact Information

The Credentialing Contact is the individual responsible for credentialing at your organization. The individual named will receive credentialing documents to sign and return to Health Partners Plans.

Credentialing Contact First Name *

Credentialing Contact Last Name *

Credentialing Contact Email *

Credentialing Contact Phone Number *

Additional Information/Notes

Health care providers must adhere to the Principles of Ethics of the American Medical Association, The American Osteopathic Association or other appropriate professional organization.

By checking the box below, I confirm that I will attend at least one Health Partners Plans-sponsored provider education training session annually. *

I agree

Attestation Provider Name or Authorized Name *

Attestation Date *

Facility/Ancillary Providers

Applying As *

Are you joining an existing participating group?

Yes

Group Information

# of additional providers in group *

Ancillary Services

Additional Provider Types Associated with Hospital

Group Name (as listed on the W-9) *

Facility Name *

d/b/a (if applicable)

TIN *

Group NPI

Group PROMISe ID Number

Federal Medicare Number *

Street Address *

City *

County

State *

ZIP Code *

Contracting Contact Information

The Contracting Contact is the individual responsible for signing contracts. The individual named will receive contracts electronically to sign and return to Health Partners Plans.

Contracting Contact First Name *

Contracting Contact Last Name *

Contracting Contact Email *

Contracting Contact Phone Number *

Contracting Contact Fax *

Hospital Affiliation *

Other Affiliation

Credentialing Contact Information

The Credentialing Contact is the individual responsible for credentialing at your organization. The individual named will receive credentialing documents to sign and return to Health Partners Plans.

Credentialing Contact First Name *

Credentialing Contact Last Name *

emailCred *

Credentialing Contact Phone Number *

Additional Information/Notes

Health care providers must adhere to the Principles of Ethics of the American Medical Association, The American Osteopathic Association or other appropriate professional organization.

By checking the box below, I confirm that I will attend at least one Health Partners Plans-sponsored provider education training session annually. *

I agree

Attestation Provider Name or Authorized Name *

Attestation Date *

Practitioner/Group Providers

Applying As *

Are you joining an existing participating (contracted) group?

Yes

Are you adding an additional location to an existing participating group?

Yes

Group Information

# of additional providers in group *

Group Name (as listed on the W-9) *

Facility Name *

d/b/a (if applicable)

TIN *

Group NPI

Group PROMISe ID Number

Provider Information

Provider Title

Provider First Name *

Provider Last Name *

Birth Date *

Individual NPI *

PROMISe ID Number *

Federal Medicare Number *

Medical License Number *

Board Certified

CAQH ID

NO CAQH ID

Street Address *

City *

County

State *

ZIP Code *

Provider Email *

Provider Phone Number *

Provider Fax *

Hospital Affiliation *

Other Affiliation *

Ethnicity

Languages Spoken (select one or more) *

English

Spanish

Chinese

Italian

Farsi

Mandarin

Arabic

French

Korean

Russian

Hindi

German

Polish

Portuguese

Japanese

Persian

Dari

Gujrati

Telugu

Practicing Specialty For Directory *

Contracting Contact Information

The Contracting Contact is the individual responsible for signing contracts. The individual named will receive contracts electronically to sign and return to Health Partners Plans.

Contracting Contact First Name *

Contracting Contact Last Name *

Contracting Contact Email *

Contracting Contact Phone Number *

Contracting Contact Fax *

Credentialing Contact Information

The Credentialing Contact is the individual responsible for credentialing at your organization. The individual named will receive credentialing documents to sign and return to Health Partners Plans.

Credentialing Contact First Name *

Credentialing Contact Last Name *

Credentialing Contact Email *

Credentialing Contact Phone Number *

Additional Information/Notes

Health care providers must adhere to the Principles of Ethics of the American Medical Association, The American Osteopathic Association or other appropriate professional organization.

By checking the box below, I confirm that I will attend at least one Health Partners Plans-sponsored provider education training session annually. *

I agree

Attestation Provider Name or Authorized Name *

Attestation Date *

Allied Health Providers

Applying As *

Confirmation of Allied Health Designation

Applying as a/an

Individual

Group

Are you joining an existing participating (contracted) group?

Yes

Are you adding an additional location to an existing participating group?

Yes

Group Information

# of additional providers in group you are joining *

Ancillary Services

Additional Provider Types Associated with Hospital

Group Name (as listed on the W-9) *

Facility Name *

d/b/a (if applicable)

TIN *

Group NPI

Group PROMISe ID Number

Provider Information

Provider Title

Provider First Name *

Provider Last Name *

Birth Date *

Individual NPI *

PROMISe ID *

Federal Medicare Number *

Medical License Number *

Street Address *

City *

County

State *

Zip Code *

Provider Email *

Provider Phone Number *

Provider Fax *

Hospital Affiliation

Other Affiliation

Ethnicity

Languages Spoken (select one or more) *

English

Spanish

Chinese

Italian

Farsi

Mandarin

Arabic

French

Korean

Russian

Hindi

German

Polish

Portuguese

Japanese

Persian

Dari

Gujrati

Telugu

Practicing Specialty for Directory *

Contracting Contact Information

The Contracting Contact is the individual responsible for signing contracts. The individual named will receive contracts electronically to sign and return to Health Partners Plans.

Contracting Contact First Name *

Contracting Contact Last Name *

Contracting Contact Email *

Contracting Contact Phone Number *

Contracting Contact Fax *

Credentialing Contact Information

The Credentialing Contact is the individual responsible for credentialing at your organization. The individual named will receive credentialing documents to sign and return to Health Partners Plans.

Credentialing Contact First Name *

Credentialing Contact Last Name *

Credentialing Contact Email *

Credentialing Contact Phone Number *

Additional Information/Notes

Health care providers must adhere to the Principles of Ethics of the American Medical Association, The American Osteopathic Association or other appropriate professional organization.

By checking the box below, I confirm that I will attend at least one Health Partners Plans-sponsored provider education training session annually. *

I agree

Attestation Provider Name or Authorized Name *

Attestation date *

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