Oct 2025 Limited Provider Request Form

Hospital Based Provider Load Request

Hospital Based provider are licensed independent Practitioners that provide services exclusively in a hospital setting.
Provider Type:*

Hospital BasedOther
Please select your Specialty, if you do not see your specialty please select "Other". *
The University of Michigan Health Plan is no longer accepting or processing applications for credentialing due to the planned wind down of our Health Plan. 
Practitioner or Facility Information
Practitioner Last Name:*
Practitioner First Name:*
Practitioner Middle Name:*
Title:*
Practitioner Date of Birth:*

MonthDayYear
Date
Social Security Number:*
Medicare Number:
Individual Type 1 NPI: *
Facility/Practice Type 2 NPI: *
CAQH ID:*
Michigan State License:*
Michigan Controlled Substance License:
DEA Number:
Is Practitioner Board Certified or Residency Trained?
Practice Information
Practice Name:*
Provider's Specialty at this Location:*
Additional Specialties or Subspecialties:
Start Date at this Location:*

MonthDayYear
Date
Corporation Name/Tax Name:*
Tax ID (Please Attach W-9 At Bottom of Form):*
Practice Physical Address
Location 1 Address (Primary Location):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Practice Manager Name:
Practice Manager's Email Address:*
example@example.com
Do you have another Practice location? *
Location 2 Address (Alternate Location 1): *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Location 2 Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Location 2 Fax Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Location 2 Practice Manager Name:
Location 2 Practice Manager's Email Address:*
example@example.com
Do you have another Practice location? *
Location 3 Address (Alternate Location 2): *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Location 3 Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Location 3 Fax Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Location 3 Practice Manager Name:
Location 3 Practice Manager's Email Address:*
example@example.com
Billing Information
Please select which practice address should be used as the Billing Address:*

Location 1 Address (Primary Location)Location 2 Address (Alternate Location 1)Location 3 Address (Alternate Location 2)Other
Billing Address Information:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Billing Fax Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Billing Contact Name:
Billing Contact Email Address:*
example@example.com
This billing information is for the following locations (select all that apply):

Location 1 Address (Primary Location)Location 2 Address (Alternate Location 1)Location 3 Address (Alternate Location 2)
Do you have a second Billing Address?*
Please select which practice address should be used as the second Billing Address:

Location 1 Address (Primary Location)Location 2 Address (Alternate Location 1)Location 3 Address (Alternate Location 2)Other
Second Billing Address Information:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Second Billing Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Second Billing Fax Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Second Billing Contact Name:
Second Billing Contact Email Address:*
example@example.com
This billing information is for the following locations (select all that apply):

Location 1 Address (Primary Location)Location 2 Address (Alternate Location 1)Location 3 Address (Alternate Location 2)
Do you have a third Billing Address?*
Please select which practice address should be used as the third Billing Address:

Location 1 Address (Primary Location)Location 2 Address (Alternate Location 1)Location 3 Address (Alternate Location 2)Other
Third Billing Address Information:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Third Billing Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Third Billing Fax Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Third Billing Contact Name:
Third Billing Contact Email Address:*
example@example.com
This billing information is for the following locations (select all that apply):

Location 1 Address (Primary Location)Location 2 Address (Alternate Location 1)Location 3 Address (Alternate Location 2)
Correspondence/Mailing Address
Is correspondence/mailing address the same as practice address?*

YesNo
Correspondence/Mailing Address Information:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Correspondence/Mailing Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Correspondence/Mailing Fax Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Correspondence/Mailing Contact Name:*
Correspondence/Mailing Contact Email Address:*
example@example.com
Main Contact
First Name:*
Last Name:*
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
Position:
Email:*
example@example.com
Please attach required W-9 if applicable:*

Cancelof
Please verify that you are human*
Should be Empty:

Hospital Based Provider Load Request

Practitioner or Facility Information

Practice Information

Practice Physical Address

Billing Information

Correspondence/Mailing Address

Main Contact