Multiplan Physician Application Form – Fill Out and Use This PDF

The Multiplan Physician Application form is a gateway for physicians looking to affiliate with MultiPlan, Inc., enabling their qualification for participation in the PHCS Network and The MultiPlan Network. This comprehensive form seeks detailed information, from personal and professional credentials to office accessibility and insurance details, to streamline the process of referrals and ensure timely payment of claims. Ready to become part of a vast healthcare network? Click the button below to start filling out your application form.

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Multiplan Physician Application Form PDF Details

Healthcare professionals seeking to expand their reach and streamline processes within their practice will find the Multiplan Physician Application form to be of substantial value. Designed to facilitate the inclusion of physicians into the MultiPlan, Inc. networks, including both the PHCS Network and The MultiPlan Network, this application is pivotal for those aiming to enhance the referral process and ensure the timely payment of claims. Completing the application requires attention to detail as it covers a comprehensive spectrum of information, from personal and contact details to professional qualifications, communication abilities, and insurance information. It also outlines the need for accuracy in listing primary and secondary practice addresses to assist in proper claim payment. Moreover, the application emphasizes the importance of maintaining current professional liability insurance limits and includes sections devoted to tax information crucial for accurate financial transactions. Physicians are encouraged to provide detailed information regarding their availability to new patients and their office's accessibility features, aiming to make healthcare more inclusive and efficient. By ensuring that all items are accurately filled out, healthcare providers can expedite their participation in networks that significantly extend their services to a wider patient base.

Question	Answer
Form Name	Multiplan Physician Application Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	prvp077, multiplan provider credentialing, multiplan practitioner application form, multiplan provider enrollment

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Arkansas Preferred Physician Application

Page 1

For MultiPlan Use Only

Thank you for your interest in participating with MultiPlan, Inc. This application will serve to qualify you for participation in both the PHCS Network (primary PPO) and The MultiPlan Network (complementary network). To ensure appropriate referrals and facilitate timely payment of claims, we ask that you complete all items on this form. Items marked with an asterisk (*) will be kept confidential to the extent permitted by law. If you need assistance completing this form, please call our Service Operations Department at 1-800-950-7040.

REGISTRATION INSURANCE LANGUAGES PROF HISTORY CERTIFICATIONS INDICATIVE

ADDRESSES

LAST NAME

FIRST NAME

M.I.

TITLE (e.g., Jr., Sr., III)

*SOCIAL SECURITY NUMBER

*BIRTH DATE (mm/dd/yyyy)

GENDER

–

E-MAIL_______________________________________

Specialty

Please indicate the specialties in which you would like to receive referrals for new patients.

Primary Specialty

Other

Education

Medical School

City, State

Degree Awarded

■

Country

Attended (mm/dd/yyyy)

From

Please indicate language(s) spoken by provider in addition to English ______________________________________________________________________________

Please indicate if you communicate in Sign Language

■ Yes ■ No

Professional Liability (Malpractice)

Do you intend to maintain your current professional liability insurance limits?

If no, please enclose a detailed explanation. ■ Yes ■ No

Comprehensive General Liability

Carrier

Expiration Date (mm/dd/yyyy)

Levels:

Per Occurrence

In Aggregate

DEA Certification

*Do you administer or prescribe controlled substances (Schedule II, III, V medications)?

ARKANSAS STATE MEDICAL BOARD

■ Yes:

DEA Certificate #

–

LICENSE NUMBER:

_______________________________________________

■ No:

I do not administer or prescribe controlled substances; I do not have a DEA number.

Address Information I

•Please provide practice, billing and mailing information for each office in which you see patients under this contract.

•Attach additional sheets if necessary.

Address 1 (Please provide your payment address first. Note: If this is also a practice address, it cannot be a P.O. Box.)

■ Payment Address

■ Practice Address

■ Mailing Address

Street

Suite

City

State

Zip

Phone Numbers

Appointments

Billing

–

Ext.

–

Ext.

Fax

–

Is This Office

Your primary practice location?

■ Yes

■ No

An address you wish to appear in the directory? ■ Yes

■ No

Open to new patients? ■ Yes

■ No

Accessible to handicapped patients?

■ Yes ■ No

Office Hours

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

From - To

After hours call coverage __________________________________________________________________________________________________________________

* Information will be kept confidential to the extent permitted by law.

PRVP077-AR (12/07)

Multiplan Physician Application Form – Fill Out and Use This PDF

Multiplan Physician Application Form PDF Details

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