Join Our Network Form | Health Network One

Join Our Network

Please complete the form and a member of our Network Development team will follow up to answer questions. If you'd like to proceed, we'll initiate the creation of a Participation Agreement as well as start the Credentialing process.

Please select your specialty Dermatology Gastroenterology Podiatry Urology Other

Name of Practice

Contact Person

NPI

TIN

Verify Email

Phone

Fax

Address

Address 2

City

State

Zip

County

Line of Business (Select all that apply) Medicaid Medicare

Minimum Age Seen

Maximum Age Seen

Which health plan(s) would you like to join?

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