SilverSummit Healthplan Provider Application Form

SilverSummit Healthplan Provider Application Form

Please see mandatory requirements below so your application can be considered:

The following documents need to be completed in its entirety and attached before consideration to be added to the SSHP Network

W-9
For practitioners, this form is required: Practitioner Data Form Or Roster.
For facilities, this form is required: Facility Checklist and Form

Become a Provider

Thank you for your interest in participating with SilverSummit Healthplan. We are excited that you selected our provider network as your network of choice. We would like to build the best network to meet member needs.

To Join our network, please fill out the application below:

Legal Entity Name (as indicated on the W9)*

DBA*

Group NPI*

Individual NPI*

Taxonomy Code*

Taxonomy Description*

Medicaid Provider Type*

Select

Is this Behavioral Health?*

Select

Physical Health Specialty Type of Provider

Select or enter value

Other (Specify)*

Behavioral Health Services Programs Provided

Select or enter value

Networks*

Select

Provider Contact First Name*

Provider Contact Last Name*

Provider's Contact Phone Number*

Provider's Email Address*

Main Address Where Services will be rendered*

City*

State*

Zip Code *

County*

Population Served*

Select

Gender Restrictions*

Select

Billing Contact Name*

Billing Phone Number*

Billing Email Address*

Office Administrator Name*

Office Administrator Phone Number*

Office Administrator Email Address*

Attach Practitioner Data Form or Roster

Attached Facility Form

Attached W9*

Attached Documents*

Drag and drop files here or

Send me a copy of my responses

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