If you like our HMO or PPO plan, but your physician isn’t in our network, we’d like to invite your physician to join our team. Complete this form to electronically submit your request.

If the physician is interested in becoming a HAP provider, the Provider Development department will initiate the credenitialing process. Contingent upon the physician's response, the anticipated timeframe for completiing the process to add the physician is 7 to 10 business days. To follow-up on the status of your physician request, please contact our Client Services Deparment.

Please provide your name so we may let the physician know of your interest; and your phone number, if we may contact you regarding your request.

Please provide your Member ID from your HAP Senior Plus or Alliance Medicare PPO membership card.

Requestor’s Name:
Member ID:
Member Phone Number:
Physician Name:
Physician Phone Number:
Physician Street Address or City:
Is this an Internal Medicine Physician or Family Practitioner?	Yes No
Physician Specialty, If Applicable: