Provider Intent Form Data Secure This site is secure

Provider Intent Form

  • Welcome!
  • 1. Provider Info
  • 2. Location(s)
  • 3. Additional Info
  • 4. Submit!
Welcome to the Hometown Health Provider Intent Form!
Please complete the following form to submit a request as a provider, or on behalf of a provider, to become part of Hometown Health's provider network! The form only takes minutes to complete!
Please note, this portal is used for non-contracted providers who would like to contract with Hometown Health. If a provider needs to be added to an existing contract with Hometown Health, please fill out the Provider Addition Form located here.
Provider Info
Requestor Info
Phone:
•
•
Ext
Add up to five (5) different locations (at least one (1) is required).
+ Add Location
1.) Is this provider a member of group?
2.) Does this provider have any hospital affiliations? If so, please tell us about it:
3.)
Please tell us any additional information about your practice that may help Hometown Health make a decision:
You are ready to submit your application!
Please review your application before submitting.
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Thank you!

Your request to become part of Hometown Health's provider network has been successfully submitted. You should be hearing back from us in the next 30-45 business days (excluding holidays).

You should also be receiving an email acknowledging that your request has been submitted. If you do not receive this email, please check your spam or junk folder and be sure to add us to your "safe sender" list. This is often done by marking the email as "not spam" or "not junk".

Click here to return to the main site.

We're sorry, but there's been an error.

We apologize for any inconvenience this may have caused. Please see the below error.

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What information do I need?
  • Provider name (first and last), title, degree, and specialty.
  • Provider's tax ID and NPI identification numbers.
  • At least one (1) location, including address, phone, fax, email, and contact name.
  • If applicable, group name and any hospital affiliations.
  • Any additional information that may be useful in helping Hometown Health make a determination.
[remove this location]
Location Info
Contact
Phone:
•
•
Ext
Fax:
•
•
Email:

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