Provider Interest Form

Thank you for your interest in participating with Banner Plans & Networks. Please complete the following online form. After completing the form, you will be asked to attach documents to complete your request.

(* 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

Select all specialties or provider types for which you would like to contract.*

Other Speciality

Practice Location #1 (Address, Suite) *

Practice Location #1 City, State, Zip *

Practice Location #2 (Address, Suite)

Practice Location #2 City, State, Zip

Group TIN *

If applicable, provide your Group NPI #

If applicable, provide your Group AHCCCS #

Do you use an Electronic Health Record (EHR) to electronically document and maintain your patients’ complete health records?

Contact information

Primary Contract Contact Information

First Name *

Last Name *

Email *

Phone Number *

Fax Number *

Name of person who will sign contract *

Email of the person signing the contract *

Credentialing Contact Information

First Name *

Last Name *

Email *

Phone Number *

Fax Number *

Which hospitals are used by practitioners in your practice? If your practice or organization does not use hospitals, please skip to the following section.

County


Hospitals

Which patient populations does your practice specialize in? (check all that apply)

Tribal members

Military Veterans

Refugees

Religious groups

Special Cultures

Traditional healing methods

LGBT+

HIV/AIDS

Other

Please enter a comment

Please add information about any special services provided by your practice, populations served, or other information that will be important for us to consider when making a contracting decision.

How do you wish to be contracted? Select all that apply: *

Ancillary/Facility

Behavioral Health

Behavioral Health Hospital

Hospital

Primary Care

Specialty

Do you offer appointments using telemedicine? * Yes No

Do you provide mobile services? * Yes No