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Behavioral Health Providers

1. What is the name and title of the provider(s) requesting to join the BHP network?
2. Is the provider joining or part of an existing group practice?
If so, please enter the group's name and TIN below.
Name
TIN
3. Where is the provider's primary office located?
  Address:
  City:
  State:
  Zip Code:
  County
  Does the provider practice in other locations? Yes No
4. What are your patient care hours?
5. What is the age range of patients you treat?
  18 years and older
  21 years and older
  less than 18 years of age only
  Other (see below)
  If you checked "Other" above, please indicate your patient age range in the box below.
6. Please indicate what specific areas of behavioral health you specialize in
(For example: depression, eating disorders, PTSD, substance abuse, personality disorders, marriage counseling, etc.)
 
7. Do you treat patients with autism? Yes No
  If yes, do you have a Medical Assistance Provider #? Yes No
8. Does the provider have staff privileges at a BHP network hospital?
(Check all that apply)
Brandywine
Schuylkill Medical Center - South Jackson
Ephrata Community Hospital
St. Christopher's Hospital For Children
Gnaden Huetten Memorial Hospital
St. Luke's Hospital of Allentown / Bethlehem
Palmerton Hospital
St. Luke's Hospital of Quakertown
Pottstown Memorial Medical Center
St. Luke's Miners Memorial Hospital
Sacred Heart Hospital
St. Joseph's Medical Center
Saint Catherine Medical Center - Fountain Springs
The Reading Hospital and Medical Center
Schuylkill Medical Center - E. Norwegian Street
None
Other (please list)
9. Is the provider currently associated with a Physician Health Organization (PHO)?
If so, please list which PHO(s).
10. Who may we contact regarding this request for network participation?
Name:
Title:
Company:
Address:
City:
State:
Zip Code:
Phone:
- - Extension:
Fax:
- -
Email: