New Provider Contact Intake Form

Thank you for your interest in joining The Alliance network of providers. The Alliance determines provider network growth based on: employer needs and network adequacy for our enrollees. The Alliance will review your information and will contact you within the next few weeks regarding our decision of your application.

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    Step 1:

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    Step 2:

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  • http://www.mywebsite.com
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  • Please enter a number greater than or equal to 1.
  • Contact Person (for contract negotiation)

  • Contact Person (for formal notices)