Get the free Provider/Practice Affiliation Request - Security Health Plan
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1515 North Saint Joseph Avenue PO Box 8000 Marsh field, WI 544498000 1.800.472.2363 715.221.9555 TTY: 711 or 7152219898 Fax 7152219500Provider/Practice Affiliation Request To be completed by requesting
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What is providerpractice affiliation request?
Provider practice affiliation request is a formal application submitted by a healthcare provider to disclose their affiliations with specific healthcare practices.
Who is required to file providerpractice affiliation request?
All healthcare providers who have affiliations with specific practices are required to file provider practice affiliation requests.
How to fill out providerpractice affiliation request?
Provider practice affiliation requests can be filled out online through the designated portal or submitted via mail with the required information.
What is the purpose of providerpractice affiliation request?
The purpose of provider practice affiliation request is to ensure transparency and disclosure of any affiliations that healthcare providers may have with specific practices.
What information must be reported on providerpractice affiliation request?
Provider practice affiliation requests must include details of the healthcare provider's affiliations with specific practices, including names, addresses, and nature of the affiliations.
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