Hospital System Contract Initiation
Complete this form to initiate a contract inquiry between your hospital system and the insurance carrier. Submission does not obligate either party.
Section #1: Insurance Carrier Information
Insurance Carrier Name
Legal Entity Name
Carrier Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Website
Primary Contracting Contact
Name
First Name
Last Name
Title
Department
Email
example@example.com
Direct Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Section #2 Hospital System Information
Hospital System/Health System Name
Parent Organization (if applicable)
Primary Administrative Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list all facilities to be considered: Facility Name, Facility Type, & NPI
Section 3: Contracting Request Details
Purpose of Inquiry:
New Network Participation
Network Expansion
Renewal/Re-Contracting
Other
Requested Participation Type:
Inpatient
Outpatient
Both
Proposed Effective Date:
-
Month
-
Day
Year
Date
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Section 4: Products / Lines of Business
Please indicate applicable plans:
Commercial
Medicare Advantage
Medicaid / Managed Medicaid
Exchange / Marketplace
Employer-Sponsored / ASO
Other
Section 5: Products / Lines of Business
Please indicate applicable plans:
Commercial
Medicare Advantage
Medicaid/Managed Medicaid
Exchange/Marketplace
Employer-Sponsored/ASO
Other
Section 6: Service Lines Requested
Type a question
Acute Care
Emergency Services
Behavioral Health
Surgical Services
Imaging/Diagnostics
Ancillary Services
Other
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Service 7: Credentialing & Delegation
Does the hospital system maintain delegated credentialing?
Yes
No
CAQH or Credentialing Platform Used?
Primary Contact for Credentialing:
Section 8: Required Documentation (to initiate process)
Facility NPIs
W-9(s)
State Licenses
Accreditation (Joint Commission, DNV, etc.)
Proof of Liability Coverage
Organizational Chart
Other
Section 9: Disclaimers
Submission of this form constitutes an inquiry only and does not obligate either party to enter into a contract. Contracting is subject to review, negotiation, credentialing, and approval by both parties.
Section 10: Carrier Authorization
Authorized Carrier Representative Name:
Title:
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: