• Provider Participation Form

  • Become a provider in our community

    To join our network, please complete this Participation Request form. Once your request has been reviewed for network need, you will be notified by mail. Please note this is not an application. Submission of this form does not guarantee participation with Affinity Health Plan.

     
     
     
     
     
     
     
     
                
       
     
     
     
     

     
     
    Requesting participation as a:
     
     
     
     
     
     
     
     
     
     
    Requesting participation as a:
     
     
     
     
     
     
     
     

    Office Hours (e.g. 08:00 am to 05:00 pm)

     
     
     
     
     
     
     

     

     

     

    Have you taken Cultural Competency Training:
    Primary Specialty:
     
    Secondary Specialty:
     

    Primary Hospital Privileges

     

    You will be asked to submit current copies of your W-9, Hospital Affiliation Letter, updated curriculum vitae (CV) and Board Certification after this form has been processed.

    If accepted, you will be required to submit a credentialing application or apply through the Council for Affordable Quality Healthcare (CAQH). Please ensure that you grant Affinity Health Plan access to your CAQH records. If you are not participating with CAQH, you may go through the CAQH website: http://caqh.org/credapp to complete an application.

     
     

Company Name Affinity Health Plan

 

The mission of Affinity Health Plan is to improve the health and well-being of its Members, their families, and their communities in collaboration with primary care providers.

Affinity strives to be the health plan of choice for its Members and its providers -- known for assuring access to high quality, cost-effective care; delivering the best customer experience; and contributing significantly to achieving a patient-centered health care system.

Contact Us

Affinity Health Plan
1776 Eastchester Road
Bronx, New York, 10461
Fax:718.794.7804
TTY/TDD users:711
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