• 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.