Contracting With Peoples Health Provider Application for Contracting with Peoples Health Fields marked with an asterisk (*) are required. 1 Please enter your information below.2 Please confirm your information is correct and click submit. 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*Select OneHospitalAncillary FacilityIndividual PhysicianPhysician GroupExisting Physician GroupContact Name* First Last Physician Name* First Last Physician Type* Primary Care Physician Specialist Multi-specialist Physician Type - OtherPhysician Degree* MD DD DMD DPM DC DO Physician Degree - OtherHospital Name*Ancillary Facility Name*Legal Entity/DBA*Legal Entity*Practice Name*DBA/Practice Name*Office or Facility Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Office Address (include building or suite number)* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Fax*Email* Hours of Operation*Specialty 1Specialty 2Services Provided*Additional information and commentsPlease 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 addressBoard Certified*YesNoPrimary CertificationSecondary CertificationList 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*MedicaidCAQH Additional Locations (include building or suite number)Location 1 Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Location 2 Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Location 3 Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Provide the required information in this section for each location listed above. You may include up to 3 additional locations on this application.*NPI *TIN *Medicare /PTAN*MedicaidCAQH Languages (other than English) spoken at primary locationAdditional information and commentsPlease 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 addressPlease attach a curriculum vitae for each physician at your practice or facility. Drop files here or Accepted file types: pdf, jpg, tif, gif, doc, docx, xls, xlsx. Please attach a curriculum vitae. Drop files here or Accepted file types: pdf, jpg, tif, gif, doc, docx, xls, xlsx. {all_fields} Click the submit button when you have completed the application. From the next screen, you can print or save a copy of your application.