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Join Our Provider Network

Allied Health Providers

1. What is the name and title of the provider(s) requesting to join the BHP network?
2. What is the providers specialty?
3. Is the provider joining or part of an existing group practice?
If so, please enter the group's name and TIN below.
Name
TIN
4. Where is the provider's primary office located?
  Address:
  City:
  State:
  Zip Code:
  County
  Does the provider practice in other locations? Yes No
5. What are your patient care hours?
6. Does the provider have staff privileges at a BHP network hospital?
(Check all that apply)
Brandywine Sacred Heart Hospital
Ephrata Community Hospital St. Luke's Hospital of Allentown / Bethlehem
Good Samaritan Regional Medical Center (Pottsville) St. Luke's Miners Memorial Hospital
Gnaden Huetten Memorial Hospital St. Luke's Hospital of Quakertown
Palmerton Hospital St. Joseph's Medical Center
Pottstown Memorial Medical Center Other (please list)
Pottsville Hospital and Warne Clinic  
The Reading Hospital and Medical Center None
7. Is the provider currently associated with a Physician Health Organization (PHO)?
If so, please list which PHO(s).
8. Who may we contact regarding this request for network participation?
Name:
Title:
Company:
Address:
City:
State:
Zip Code:
Phone: - - Extension:
Fax: - -
Email: