California Healthcare Networks Application for Direct Provider Participation


 
Please provide all information requested.  Additionally, this application is for submittal of an application into the California Healthcare Networks.  Upon medical advisory board review, a Provider Participation Agreement will be sent to you by email, fax, or USPS delivery.  Upon receipt of your complete packet, credentialing, and verification, you will be notified of acceptance and participation in CHN.
CHN Application for Direct Provider Participation
Provider's First Name *
Provider's Last Name *
Gender *
Discipline *
Practice Name *
Provider DOB *
Location of Birth (City, ST) *
U.S. Citizen *
SSN or Tax ID# *
Name Affiliated with ID# *
Specialty Interests
Specialty Training
2008 National Physician Identifier # (NPI) *
Primary Office Address *
City *
State *
Zip Code *
Primary Contact Person *
Phone # *
Fax #
E-mail Address *
Secondary Office Address
City
State
Zip Code
Secondary Contact Person
Phone #
Fax #
E-mail Address
Please list all affiliations:  Hospitals, Surgery Centers, Rehab Facilities, Skilled Nursing Units
(1) Name
(1) City
(1) Type
(2) Name
(2) City
(2) Type
(3) Name
(3) City
(3) Type
(4) Name
(4) City
(4) Type
(5) Name
(5) City
(5) Type
(6) Name
(6) City
(6) Type
At the present time, with whom do you have contracts? Please list:
Contract Name #1
Contract Name #2
Contract Name #3
Contract Name #4
Contract Name #5
Contract Name #6
Please list any other office locations (if applicable):
#3 Office Address
City
State
Zip Code
#3 Contact Person
Phone #
Fax #
E-mail Address
#4 Office Address
City
State
Zip Code
#4 Contact Person
Phone #
Fax #
E-mail Address
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