Healthcare Provider Network Participation Request

Please complete the following form only if you are a physical therapist, occupational therapist, speech pathologist, chiropractor, massage therapist, or acupuncturist.

You must input a correct CAQH number or a valid license number with date of birth.

A separate request must be completed for each service location

First Name: *

Last Name: *

Middle Initial:

Title: *

Specialty Type: *

Email Address: *

Office Address: *

Office City: *

Office State: *

Office Zip Code: *

County: *

Office Phone: *

Office Fax: *

CAQH Number:

License Number:

Date of Birth:

In the area below, please list any professional competencies, accreditations, languages spoken, and/or any additional information that you feel should be considered when evaluating network consideration:

List of Practitioners

Please submit the list of practitioners, other than yourself, providing services at this location.

Provider 1

First Name:

Last Name:

Specialty:

Provider 2

First Name:

Last Name:

Specialty:

Provider 3

First Name:

Last Name:

Specialty:

Provider 4

First Name:

Last Name:

Specialty:

Provider 5

First Name:

Last Name:

Specialty:

Provider 6

First Name:

Last Name:

Specialty:

Provider 7

First Name:

Last Name:

Specialty:

Provider 8

First Name:

Last Name:

Specialty:

Provider 9

First Name:

Last Name:

Specialty:

Provider 10

First Name:

Last Name:

Specialty:

Requests will be kept on file for one year.