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.

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(if applicable)
Please enter a number from 0 to 50000.
Are you currently providing services to members of The Alliance?*

Contact Person (for contract negotiation)

Contact Person (for formal notices)