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Join Our Provider Network

Physicians

1. What is the name and title of the physician(s) requesting to join the BHP network?
2. What is the physicians specialty?
3. Is the physician joining or part of an existing group practice?
If yes, please enter the group's name and TIN below.
Name
TIN
4. Where is the physician's primary office located?
  Address:
  City:
  State:
  Zip Code:
  County
  Does the physician practice in other locations? Yes No
5. What are your patient care hours?
6. Does the physician 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)
 
7. Is the phyisican currently associated with a Physician Health Organization (PHO)?
If so, please list which PHO(s).
8. Who may we contact regarding this request for network participation?
Name:
Title:
Company:
Address:
City:
State:
Zip Code:
Phone: - - Extension:
Fax: - -
Email:
9. Who may we send an application regarding this request for network participation?
Same as Above:
Name:
Title:
Company:
Address:
City:
State:
Zip Code:
Phone: - - Extension:
Fax: - -
Email: