Facility / Ancillary Network Interest Form

FACILITY / ANCILLARY NETWORK INTEREST PROFILE FORM
NOTE: For multiple locations, please fill out 1 form for each company and attach a list of each company’s locations.
NOTE: Please include any additional comments/questions in the body of your email submission.
General Information
*required
*required
Contact Person*:
Email*:
Date:
*required
Phone #:
Fax #:
Tax ID #:
*required
*required
Operating Name (DBA):
License #:
*required
*required
Medicare # (Required for participation):
NPI #:
*required
Are you accredited?*
Yes**
No
Medicaid #:
**If yes, list the accrediting entity:
Provider Physical Location:
*required
Provider Specifications*
Please check all applicable services for your provider type
Home Health Nursing
Acute Hospital
Sleep Studies
Home PT/OT/ST (which?):
Cardiac Surgery
Home
Facility
Cardiac Caths
Home Infusion
Infusion/Chemotherapy
Radiation Therapy
Wound Care
Ambulatory Surgery Center
Psych Nursing
Ambulance/Transport Service
DME (must be accredited)
Dialysis
SNF
Orthotics/Prosthetics
Mobility Devices
Other Specialization:
Do you carry general and professional liability insurance? If so, how much? Please note that HealthSpring requires all of the provider
types listed above to carry both general and professional liability insurance.
General:
Professional:
Service Areas Covered*: Please list all that apply from drop-down list. Houston - Southeast Texas
Dallas/Fort Worth - North Texas
*Please attach a listing of counties covered
Are you interested in servicing multiple states? If so, please send an inquiry to HealthSpring National Contracting at:
[email protected]
Your request will be presented at a HealthSpring Network Review Committee meeting; you will be notified once a decision is rendered within 45
days. Determinations are based on network need and current availability of services. PLEASE NOTE: Requesting, obtaining, or submitting a
profile form does not guarantee or imply that you will be accepted to participate in the HealthSpring network, nor does it entitle you to payment of
any services rendered to a HealthSpring member prior to receiving written confirmation of an effective date and meeting any and all applicable
authorization requirements. All providers are subject to HealthSpring Credentialing requirements and applicable state and federal guidelines as
set forth in the HealthSpring participating provider agreement.
Please complete this form electronically and return via email to [email protected]. If this form is returned
without all required questions answered, the form will not be processed. Please allow the full 45 days before calling to verify
application status.
Email: [email protected]
Phone: (Local) 832-553-3300
(Toll Free) 1-888-501-1115