Join Our Network Form - Individual Provider

Please complete the questionnaire for our Provider Relations team. All fields marked with * are required.

Provider information

Details about the provider being added

Group Name Required

Please enter a value.

Business Name (DBA) Required

Please enter a value.

Main Practice Address Required

Please enter a value.

City Required

Please enter a value.

State Required

Zip Required

Please enter the value in format '12345'.

Main Practice Location Phone Required

Invalid phone number.

Main Practice Location Email Required

Please enter email value in format 'mymail@domain.com'.

TIN Required

Requires 9 numerical characters.

NPI Required

Requires 10 numerical characters.

Please go to https://proview.caqh.org/ to ensure your information matches the information you have included in this application.

Required

My information is current with CAQH

Required

If you are in California, do you want to join the Sutter EPO?

Credentialing Information

Enter credentialing details

Contact Name Required

Please enter a value.

Contact Phone Required

Invalid phone number.

Phone Extension (optional) Required

Contact Email Required

Please enter email value in format 'mymail@domain.com'.

Completed by

Provide contact information for the person completing this request.

Completed By Name Required

Please enter a value.

Completed By Email Required

Please enter email value in format 'mymail@domain.com'.

Completed By Phone Number Required

Invalid phone number.

Phone Extension (optional) Required

Completed By Comments Required 0/100

Please enter a value.