2023 PRACTICE NETWORK INTEREST FORM
If you are interested in becoming a contracted provider please complete the form below. Please upload a full Provider Roster for your Practice (Full Names and NPIs) and a signed and dated W9.
Please note: Applicants are reviewed quarterly. Please allow a minimum of 90-120 days from your application to be reviewed. We will follow up with your practice via the email submitted on this form. Additionally; SHA/DCHA is not a payor. When you apply to join the ACO they should simultaneously apply to be in-network with our payors Aetna, BCBS, Medicare and SmartHealth. Each payor contracts and credentials separately with your practice.
Should you have any questions please e-mail: SHAPhysicianEngagement@seton.org
***DO NOT SUBMIT THIS FORM IF YOUR PRACTICE IS ALREADY CONTRACTED WITH SHA & DCHA. IF YOUR GOAL IS TO ADD A PROVIDER TO THAT PRACTICE. TO SUBMIT A NEW PROVIDER ADD TO EXISTING CONTRACTED GROUP USE THIS LINK: https://redcap.ascension.org/txaus/surveys/?s=RDWWRKTWEH