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Join Presbyterian as a Contracted Provider

Please fill out this form if you are interested in partnering with Presbyterian as a contracted practitioner. Presbyterian will review your request and notify you within 14 to 21 days of our decision.

Letter of Interest

Dear Healthcare Practitioner:

On behalf of Presbyterian, I would like to take this opportunity to thank you for your interest in partnering with us as a contracted practitioner.

In addition to the information you're submitting online, we will also need a copy of your current CRS-1 form and W-9 form. Please fax these to 505-923-5400.

In order for our Provider Services Network Team to appropriately review your request, we ask that you complete the information, below, and press the "Send my Request" button to reply.

Thank you for expressing an interest in partnering with us to improve the health of individuals, families and communities

* Denotes mandatory field

*Practitioner Last Name:
*Practitioner First Name:
*Practitioner Middle Name:
*Specialty:
*Overview of Services Performed:
*Gender Male Female
*Federal Tax ID Number
Unique Physician Identification Number (UPIN)
*National Provider Identifier Number (NPI)
(Find out more about NPI)
*Provider Taxonomy Code
(Located on your NPI application )
*State Professional License/Certification Number
DEA Number
Pending N/A
*Hospital Privileges
*Office Manager or Contact Person
*Office Manager or Contact Telephone Number:

Practice/Group Name

Effective Date
*Street Address
*City
*State
*Zip Code
*Telephone Number
*Fax Number
E-mail Address
Can we contact you by e-mail for correspondence? Yes No
*Foreign Languages (spoken fluently by practitioner)
*Foreign Languages (spoken fluently at practice)
Current Mailing Address (if different from above)
Same As Above
*Street Address
*City
*State
*Zip Code
*Telephone Number
*Fax Number
Billing Address (if different from mailing address)
Same As Practice Address Same As Mailing Address
Contact Person
*Street Address
*City
*State
*Zip Code
*Telephone Number
*Fax Number
Other Practice Locations

Practice Name
Street Address
City
State
Zip Code
Telephone Number
Fax Number
Practice Associate I
Last
First
MI
License #
DEA #
Practice Associate II
License #
DEA #
Practice Associate III
License #
DEA #
Practice Associate IV
License #
DEA #
Practice Associate V
*What are the office hours for your Practice or Group Practice? (Provide days/hours)

*Do you have the means and ability to bill and submit claims electronically?
Yes No

PCPs

We are interested in adding physicians to our panel that are interested in caring for a large enough group of our patients to make a measurable difference in improving their health. Are you willing to have at least 50 PHP members in the next 6 months assigned to you as their PCP?

Yes No

Specialists

We are interested in adding physicians to our panel that are interested in caring for a large enough group of our patients to make a measurable difference in improving their health. Are you willing to have at least 50 unique PHP members in the next 6 months referred to you for specialty care?

Yes No

Additional Comments/Questions

Reminder: Please do not forget to fax a copy of your CRS-1 form and W-9. Your application may be delayed until these are received.

Attach supporting documentation

File 1


File 2


File 3

Presbyterian is working to move as much communication as possible to email in order to redirect administrative funds to patient care. All other things being equal, preference will be given to those practitioners with Internet access and the capability to file claims electronically.

Upon receipt of your letter, Presbyterian will review your request & notify you within 14 to 21 days of Presbyterian's decision. Thank you for expressing an interest in partnering with us to improve the health of individuals, families & communities.