Online application for providers looking to contract with Peoples Health

To submit a request to join the Peoples Health provider network, please complete the online application below. Contracting is limited to our service area. Peoples Health plans serve all Louisiana parishes. The application may take 15-30 minutes to complete. Please have all required information available before proceeding, as incomplete applications cannot be processed.

You must complete all required fields and attach a curriculum vitae for each provider at your practice or facility who is interested in contracting with Peoples Health. Required fields are noted with an asterisk. Please have available your Medicare/PTAN and TIN numbers, as well as your Medicaid and CAQH numbers if applicable. If you have applied for a Medicare number and haven’t yet received it, please contact Medicare for a status update. Do not submit an application until the number has been issued. Include the following in the Additional Information and Comments section:

Areas serviced, including any special services offered
Any area hospitals with which you have an association (list hospital and status, for example, active, courtesy, temp, etc.)
Mailing address if different from service address

Provider Type*

Contact Name*

First Last

Physician Name*

First Last

Physician Type*

Primary Care Physician
Specialist
Multi-specialist

Physician Type - Other

Physician Degree*

Physician Degree - Other

Hospital Name*

Ancillary Facility Name*

Legal Entity/DBA*

Legal Entity*

Practice Name*

DBA/Practice Name*

Office or Facility Address*

Street Address Address Line 2 City State ZIP Code

Primary Office Address (include building or suite number)*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax*

Email*

Hours of Operation*

Specialty 1

Specialty 2

Services Provided*

Additional information and comments

Please include areas serviced; any special services offered; any area hospitals with which you have an association, list hospital and status, for example, active, courtesy, temp, etc.; and your mailing address if different from your service address

Board Certified*

Yes
No

Primary Certification

Secondary Certification

List all practicing physicians at this location (you may include up to 10), or attach a physician roster.*

Physician First Name *	Physician Last Name *	Specialty *	NPI *	TIN *	Medicare /PTAN*	Medicaid	CAQH

Additional Locations (include building or suite number)

Location 1

Street Address Address Line 2 City State ZIP Code

Location 2

Street Address Address Line 2 City State ZIP Code

Location 3

Street Address Address Line 2 City State ZIP Code

Languages (other than English) spoken at primary location

Additional information and comments

Please include areas serviced; any special services offered; any area hospitals with which you have an association, list hospital and status, for example, active, courtesy, temp, etc.; and your mailing address if different from your service address

Please attach a curriculum vitae for each physician at your practice or facility.

Drop files here or

Please attach a curriculum vitae.

Drop files here or

Contracting With Peoples Health

Additional Locations (include building or suite number)