Birth Date (MM/DD/YYYY)
I have no CAQH ID
Group NPI (for primary location)
Practice, Facility or Company
Ancillary Services (required when applying as Ancillary)
Abington Health Center - Warminster
Abington Health Lansdale Hospital
Abington Memorial Hospital
Albert Einstein Medical Center
Aria Health – Bucks County Campus
Aria Health – Frankford Campus
Aria Health – Torresdale Campus
Bryn Mawr Hospital
Bryn Mawr Rehab Hospital
Chester County Hospital
Chestnut Hill Hospital
Crozer Chester Medical Center
Delaware County Memorial Hospital
Dupont Hospital for Children
Einstein at Elkins Park
Einstein at Montgomery
Fox Chase Cancer Center
Hahnemann University Hospital
Holy Redeemer Hospital
Hospital of the University of Penn
Jennersville Regional Hospital
Lancaster General Hospital
Lankenau Medical Center
Lower Bucks Hospital
Mercy Fitzgerald Hospital
Mercy Philadelphia Hospital
Mercy Suburban Hospital
Moss Rehab at Elkins Park
Moss Rehabilitation Hospital
Pottstown Memorial Medical Center
Presbyterian Medical Center
Roxborough Memorial Hospital
St. Christopher’s Hospital for Children
St. Luke’s Quakertown Hospital
St. Mary Medical Center
Temple University Hospital
Temple University Hospital - Episcopal
Weisman Children’s Rehab Hospital
Wills Eye Hospital
Other Affiliation (required if Other is selected above)
Lines of Business
Languages Spoken (other than English)
Medical License Number
Practicing Specialty For Directory
Attestation Statement and Authorization to Release Information
I hereby apply to become a
practitioner in the Health Partners Plans network. (Please check one or both.)
I certify that all of the information that I have submitted in connection with the application is true, accurate and complete. I understand that Health Partners Plans will rely on this information to evaluate my participation in the program(s) provided through Health Partners Plans.
I understand and agree that I am to adhere to and abide by the terms and conditions of this program(s) and any and all Agreements I have or will in the future enter into with Health Partners Plans.
I understand that any material misstatement or omission of fact on the application is grounds for action by Health Partners Plans, including but not limited to summary dismissal from Health Partners Plans as provided in the Provider Agreement.
I attest to having in the amounts required by the State of Pennsylvania current, valid malpractice insurance coverage and all other applicable professional insurances.
I agree to adhere to the code of ethics of the
Professional Organization *
Other Scope of Practice
If Other Scope of Practice, please specify
(AMA, AOA or other appropriate professional organization of specialty or scope of practice).
I authorize Health Partners Plans and/or its designated credentialing agent to consult with members of the medical staff, affiliate hospitals, professional liability carriers, and healthcare facilities with which I have been associated. In addition, this authorization includes consultation with other healthcare professionals who may have information bearing on my competency, character, physical health status, emotional health status, and ethical aspects of my professional practice.
I authorize release of such information to Health Partners Plans and/or its designated credentialing agent upon request. I agree a facsimile or photocopy of my signature will serve the same as the original.
I attest that I have clinical admitting privileges at the Health Partners Plans participating hospital noted on my CAQH or PA Standard application.
I agree to release all Medical Assistance records pertaining to sanctions and/or settlements to HPP and the Pennsylvania Department of Human Services.
I agree to attend at least 1 HPP sponsored provider education training session annually.
Attestation Full Name
Attestation Date (MM/DD/YYYY) *
Attestation Confirmed *