Fillable 6.6.19 Request To Add Clinician

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6.6.19 Request To Add Clinician

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The 6.6.19 Request To Add Clinician form is 1 page long and contains:

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Country of origin: OTHERS
File type: PDF

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Date of Request:
Agency Name requesting to add clinician:
Agency Practice Address:
Clinician’s Name
(as it appears on professional license):
Clinician’s Email:
Is Clinician currently credentialed with Alliance? Yes No
Applicable License Type(s) (list all):
License Number(s) (list all):
NPI Number:
Is Clinician registered with CAQH?
Yes (Provide Number):
No (Provide Date of Birth to receive registration information):
Hire Date (for HOSPITALS ONLY):
Name of Person Submitting Request:
Contact Email (where application will be sent):
Please complete request and email to: ProviderNetwork@alliancehealthplan.org
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6.6.19 Request To Add Clinician

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Completed 7 May 2021

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