New Provider Contract 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 respond to your request within the next 30 days.

Providing High-Value Health Care to Self-Funded Employers

"*" indicates required fields

Legal Name of Practice*

Doing Business As

(if applicable)

Tax ID

Primary Street Address*

Address Line 2

City*

State / Province / Region*

ZIP / Postal Code*

Country*

Phone

Website

Number of Practitioners

Please enter a number from 0 to 50000.

Specialty

Are you currently providing services to members of The Alliance?*

Yes

No

Contact Person (for contract negotiation)

First Name

Last Name

Title

Email*

Phone

Contact Person (for formal notices)

First Name

Last Name

Title

Email*

Phone