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.

  • Step 1:

  • Step 2:

  • (if applicable)
  • Please enter a number greater than or equal to 1.
  • Contact Person (for contract negotiation)

  • Contact Person (for formal notices)