Provider Participation Request Form
Members are to use this form when you would like to have Sanford Health Plan’s Provider
Contracting team contact a non-participating provider for inclusion in Sanford Health Plan’s broad
network. This document is not an application, but a request for in-network participation. Although we
cannot guarantee participation with the provider, we will review your request. We encourage you to
follow up with the provider as well.
Complete this form and submit by:
Fax: (605) 328-7224 attention Provider Contracting; or
Scan & email: SanfordHealthPlanProviderContracting@sanfordhealth.org
Member Information (please print):
___________________________________________________________________________________
Name (First & Last) Member ID# Date of Birth
___________________________________________________________________________________
Address (including City, State & Zip)
___________________________________________________________________________________
Phone Email Date Submitted
Provider Information (please print):
___________________________________________________________________________________
Name (First & Last) Degree/License (e.g. M.D., P.A., and L.P.C.)
___________________________________________________________________________________
Specialty
___________________________________________________________________________________
Clinic/Facility Name Phone
___________________________________________________________________________________
Clinic/Facility Address (including City, State & Zip)
HP-0122 4/19
