Request to Join

The CAQH application is a standard application used by most health plans in Michigan.

Please provide the following information:

*Last Name:

*First Name:

Middle Initial:

*Date of Birth:

*Email:

*Contact Name:

*Phone Number:

ext.

*Fax Number:

*Primary Specialty:

select

Secondary Specialty:

*Type of Degree:

*Applying As:

select

CAQH Provider ID:

*State License Number:

*State License State:

Website Address:

II.

Please provide your primary office location:

*Group Name:

*Street Address:

*City:

*State:

*Zip/Postal Code:

*Office Phone Number:

ext.

*Fax Number:

III.

Please provide further details:

Hospital Affiliations(s):

If you do not have
staff privileges at a
Beaumont, Crittenton
or Henry Ford Macomb
Hospital, please
indicate your intentions
for joining United
Physicians, PC:

Security Code:

*Type Security Code:

* Required Fields