Join HP Network

Join The Health Plan Network

Please complete the following form and submit.

Remember that submitting Healthcare Provider Information is not a guarantee participation or meeting The Health Plan's participating standards and guidelines.

Fields listed with an "*" are required.

Mandatory *

Corporate Name

Provider Name *

Please type the Provider Name

Address

City

County

State

ZIP Code

Phone Number *

Please include your phone number. Do not include spaces

Email Please provide a valid email, if none exists, leave blank

Please provide a valid email, if none exists, leave blank

Degree (MD, DO, etc.)

Specialty(s)

NPI #

Tax ID #

Contact Person

Contact Person Phone Number

Contact Person Email Please provide a valid email, if none exists, leave blank

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Licensed In To select multiple items, homd down the Ctrl key and select items of interest

If licensed in another state, please list

You can use upper or lower case letters...

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