Provider Recruitment Form

If you are submitting the form (below) as a Jefferson Health Plans EverWell provider, you must have a valid PA Medicaid PROMISe ID.

If you are submitting the form as a Medicare Advantage provider, you must have a valid Federal Medicare number and not be listed on the Medicare Opt-Out report.

Please be aware that this form is an inquiry for consideration and not an official registration. We will review your request and if we are in need of your specialty, a representative will contact you to help guide you through our formal application process.

Thank you for your interest in joining Jefferson Health Plans' provider network!

*Indicates required field

Medicaid Community HealthChoices - LTSS

Are you joining an existing participating (contracted) group? *

Group Information

Provider Information

Contracting Contact Information

The Contracting Contact is the individual responsible for signing contracts. The individual named will receive contracts electronically to sign and return to Health Partners Plans.

Credentialing Contact Information

The Credentialing Contact is the individual responsible for credentialing at your organization. The individual named will receive credentialing documents to sign and return to Health Partners Plans.

Is the Contracting Contact also the Credentialing Contact? *

Health care providers must adhere to the Principles of Ethics of the American Medical Association, The American Osteopathic Association or other appropriate professional organization.

By checking the box below, I confirm that I will attend at least one Jefferson Health Plans provider education training session annually. *

Facility/Ancillary Providers

Are you joining an existing participating (contracted) group? *

If applying as a new group please indicate which lines of business your organization would like to apply for or hit the select all option below. *

Group Information

Provider Information

Contracting Contact Information

The Contracting Contact is the individual responsible for signing contracts. The individual named will receive contracts electronically to sign and return to Health Partners Plans.

Credentialing Contact Information

The Credentialing Contact is the individual responsible for credentialing at your organization. The individual named will receive credentialing documents to sign and return to Health Partners Plans.

Is the Contracting Contact also the Credentialing Contact?

Health care providers must adhere to the Principles of Ethics of the American Medical Association, The American Osteopathic Association or other appropriate professional organization.

By checking the box below, I confirm that I will attend at least one Jefferson Health Plans provider education training session annually. *

Practitioner/Group Providers

Are you joining an existing participating (contracted) group? *

If applying as a new group please indicate which lines of business your organization would like to apply for or hit the select all option below. *

Group Information

Provider Information

Contracting Contact Information

The Contracting Contact is the individual responsible for signing contracts. The individual named will receive contracts electronically to sign and return to Health Partners Plans.

Credentialing Contact Information

The Credentialing Contact is the individual responsible for credentialing at your organization. The individual named will receive credentialing documents to sign and return to Health Partners Plans.

Is the Contracting Contact also the Credentialing Contact?

Health care providers must adhere to the Principles of Ethics of the American Medical Association, The American Osteopathic Association or other appropriate professional organization.

By checking the box below, I confirm that I will attend at least one Jefferson Health Plans provider education training session annually. *

Allied Health Providers

Are you joining an existing participating (contracted) group? *

If applying as a new group please indicate which lines of business your organization would like to apply for or hit the select all option below. *

Group Information

Provider Information

Contracting Contact Information

The Contracting Contact is the individual responsible for signing contracts. The individual named will receive contracts electronically to sign and return to Health Partners Plans.

Credentialing Contact Information

The Credentialing Contact is the individual responsible for credentialing at your organization. The individual named will receive credentialing documents to sign and return to Health Partners Plans.

Is the Contracting Contact also the Credentialing Contact?

Health care providers must adhere to the Principles of Ethics of the American Medical Association, The American Osteopathic Association or other appropriate professional organization.

By checking the box below, I confirm that I will attend at least one Jefferson Health Plans provider education training session annually. *