Search for:
Careers
Contact Us
How We Help
Benefit Solutions
Care Management
Network Solutions
HealthSmart Preferred
Health Payers Organization (HPO)
HealthSmart Physician & Ancillary Network
National Ancillary Solution
Workers' Compensation Network
Auto Medical Network
HealthSmart Dental California
Who We Are
About HealthSmart
Who We Serve
Health Plan Brokers
Employers
Payers
Native American Tribes
Service Centers
Member Center
Student Member Center
Employer Center
Provider Center
Payer Center
Service Centers
//
Provider Center
Join Our Network Form - Individual Provider
Please complete the questionnaire for our Provider Relations team.
Provider Information
First Name:
Required
Last Name:
Required
Business Name (DBA):
Required
Main Practice Address:
Required
City:
Required
State:
Required
AK
AL
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Required
Main Practice Location Phone:
Required
Example: (555) 555-5555 or 555-555-5555
Main Practice Location Email:
Required
TIN:
Required
NPI:
Required
Required
Please go to
https://proview.caqh.org/
to ensure your information matches the information you have included in this application.
My information is current with CAQH:
If you are in California, do you want to join the Sutter EPO?:
Credentialing Information
Contact Name:
Required
Contact Phone:
Required
Example: (555) 555-5555 or 555-555-5555
Extension:
Contact Email:
Required
Form Completed By
Completed By Name:
Required
Completed By Email:
Required
Completed By Phone:
Required
Example: (555) 555-5555 or 555-555-5555
Extension:
Comments: