Provider Interest Form - P3 Health Partners

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Provider Interest FORM.

Thank you for your interest in joining the P3 Health Partners Network. A brief initial interest profile is needed to begin the process. Please complete the questions below and submit.

Please fill out form.

Practice Information

Business name as shown on your income tax return and W9 *(Required)

Business name as shown on the second line of your W9

Practice Specialty(Required)

Practice Address

Street Address Address Line 2 City State ZIP Code

Mailing Address(Required)

Mailing Address

Street Address Address Line 2 City State ZIP Code

Currently on an EHR(Required)

If Yes, Name and Version of EHR(Required)

Group TIN(Required)

Group NPI(Required)

Contact information

Title

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Fax Number

Email the Contract(Required)

Name of Person Who Will Sign Contract(Required)

First Last

Credentialing Contact Information

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Fax Number

Email the Credentialing Application(Required)

List New Practitioners Joining Group or All Practitioners If New Practice

Provider First Name(Required)

Provider Last Name(Required)

Degree

(i.e. MD, DO, DPM, DDS, NP, PA, PhD, etc.)

Date of Birth(Required)

Provider NPI(Required)

Provider CAQH#(Required)

Hospital Admitting Privileges?(Required)

Yes

No

Which hospital do you have admitting privileges?(Required)

What is the covering arrangement?(Required)

Board Certified(Required)

Provider Roster Template

To add more providers, download provider roster template. Upload completed list below.

Provider Roster

Drop files here or

Max. file size: 50 MB.

Upload completed list here.

Provider Roster Template

If an Ancillary or Facility (e.g. ASC, Hospital, Dialysis Center, laboratory, etc), please download template. Upload completed list below.

Ancillary or Facility (e.g. ASC, Hospital, Dialysis Center, laboratory, etc)

Drop files here or

Max. file size: 50 MB.

Upload completed list here.

Attachments

W-9 Form(Required)

Drop files here or

Max. file size: 50 MB.

You may also upload any additional documents you would like reviewed.

How does the provider want to be credentialed *(Required)

Provider Specialty(Required)

Is Provider able to meet the following standards for scheduling appointments (Check all that apply):(Required)

Urgent, nonemergency visits within 24 hours

Routine visits within 14 calendar days

Sick visits within 24 hours

None of the above

If the answer is 'None of the above', please provide more details including how many days it takes to schedule each type of appointment:

Does your practice provide physician access 24 hours a day, 7 days a week?(Required)

If the answer is no please explain why not:(Required)

What are the Providers Office hours?(Required)

Do you see patients regularly?(Required)

After 5PM

Weekends

Holidays

If you don't offer regularly scheduled after-hours appointments, do you schedule an after-hours visit if needed?(Required)

Does the provider speak any foreign languages fluently? If so, please list languages(s):

Does the provider utilize any type of patient satisfaction survey?(Required)

Yes

No

If yes, please provide more details and a brief summary of results(Required)

Please list any other services Provider offers to patients:

Are you currently accepting Medicare Advantage patients?(Required)

Yes

No

Is your panel open or closed for Medicare Advantage patients?(Required)

Yes

No

Do you participate in an ACO for your Medicare Advantage population?(Required)

Yes

No

If yes, which health plans?(Required)

What state are you wanting to contract with?(Required)

Arizona

California

Nevada

Florida

Oregon

Idaho

Oklahoma

National

2370 Corporate Circle
Suite 300
Henderson, NV 89074

(702) 910-3950

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