Provider Interest Form

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

(* indicates mandatory information)

Please provide the following information

Practice Information

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

Business name as shown on the second line of your W9

Practice Specialty *

Practice Location #1 (Address, Suite)

City, State, Zip

Practice Location #2 (Address, Suite)

City, State, Zip

Mailing Address (Address, Suite)

Use Address #1Use Address #2Other

City, State, Zip

New Provider/Group to Banner *

Group TIN *

Group NPI

Group AHCCCS #

Currently on an EHR

Contact information

Primary Contact Information

First Name *

Last Name *

Email *

Phone Number *

Fax Number *

Email the Contract (Y/N) *

Name of person who will sign contract *

Credentialing Contact Information

First Name *

Last Name *

Email *

Phone Number *

Fax Number *

Email the Credentialing Application (Y/N) *

List New Practitioners Joining Group or All Practitioners If New Practice

Practice Providers Information

Provider First Name *

Provider Last Name *

Date of Birth *

Degree *

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

Provider NPI *

Provider AHCCCS #

(Required for Medicaid Participation)

Provider CAQH # *

(Required for Credentialing)

Board Certified in the specialty in which you are applying *

Added Provider(s)

Select Banner Facilities * (AT LEAST ONE BOX MUST BE CHECKED)

Facilities

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Attachments

Please note: W-9 is REQUIRED

You may also upload any additional documents you would like reviewed

File Attachments

W-9 Upload:

File:

How does the provider want to be credentialed *

Provider Specialty *

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

Urgent, nonemergency visits within 24 hours
Routine visits within 14 calendar days
Sick visits within 24 hours

If the answer is 'No' to any of the appointment scheduling standards, 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? * Yes No

If the answer is no please explain why not:

What are the Providers Office hours? * Enter time as HH:MM (ex 08:00)

Monday Office Hours: AM to PM
Tuesday Office Hours: AM to PM
Wednesday Office Hours: AM to PM
Thursday Office Hours: AM to PM
Friday Office Hours: AM to PM
Saturday Office Hours: AM to PM
Sunday Office Hours: AM to PM

Do you see patients regularly:

After 5PM * Yes No
Weekends * Yes No
Holidays * Yes No

If you do not offer regularly scheduled after hours appointments, do you occasionally schedule an after-hours visit if needed (explain):

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

Does the provider utilize any type of patient satisfaction survey? * Yes No

If yes, please provide more details and a brief summary of results:

Please list any other services Provider offers to patients:

In order to participate in certain products, Providers are required to have a direct contract with health plans and be credentialed by them. Does the Provider hold a direct contract with any of the following health plans (Check all that apply)?

Aetna Whole Health and Aetna Attribution - Commercial
Aetna Attribution - Medicare Advantage
Blue Alliance and Blue Acclaim
Cigna Collaborative Accountable Care (CAC) Attribution - Commercial
Humana Attribution Medicare Advantage
United Commercial Shared Risk

Do you participate in an ACO with any of the health plans above? * Yes No

If yes, which health plans?