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Deaconess Health Plans  /  For Providers  /  Provider Application Request

Provider Application Request

Thank you for your interest in applying for medical staff membership and/or privileges at Deaconess Health Plans, LLC and/or Deaconess Hospital, Inc. and Evansville Surgery Center, LLC. Practitioners wishing to provide services must be credentialed. Deaconess Hospital, Inc. Medical Staff and Allied Health Care providers serve the following:

  • Deaconess Hospital, Inc.
  • Deaconess Gateway Hospital
  • Deaconess Cross Pointe
  • The Women's Hospital

Deaconess Health Plans, LLC and Evansville Surgery Center are separate entities within the Deaconess Health System, Inc.

To request membership and/or privileges at one or more of the entities listed above, you only need to complete one Request for Application. To obtain an application request form to add a facility to the Deaconess Health Plans network please contact Provider Relations at 812-450-7265.

Credentialing Process

  • The first step in this process is to complete a Request for Application form.
  • Receipt of this information is a prerequisite to be considered for any further application processing.  Completion of the Request for Application does not guarantee we will offer an application or grant privileges.
  • Please be sure to include an e-mail address where indicated on the Request for Application form.

For Additional Information (If you have questions or would like to receive additional information, please call the following)

  • Deaconess Health Plans, LLC - 812-450-7265
  • Deaconess Hospital, Inc. (also includes Deaconess Gateway Hospital, Deaconess Cross Pointe, and The Women’s Hospital – 812-450-3339)
  • Evansville Surgery Center – 812-250-0124

Provider Information

Completed By:
Date Completed:
Provider's First Name:
Last Name:
MI:
Provider's Date of Birth:
Provider's Start Date:
Locum
Applying for: (check all that apply):

Credentials:
































TIN:
Individual NPI:
Primary Specialty:
Practicing Specialty:
Supervising Physician:
Board Certified?
Board Name:
Registered with CAQH?
CAQH ID:
Is Provider Joining an Existing Practice:
Does provider currently have a permanent state license, CSR(if applicable), and DEA (if applicable) for the state in which he/she will practice?

Practice Information

Practice Name: (Please indicate the name of the practice you will be joining.)
Street:
City:
State:
Zip:
County:

Application Correspondence Information

Street:
City:
State:
Zip:
Phone:
Fax:
Contact Person:
Contact Person Email:
Contact Phone:

Additional Information

Comments:

I understand that completion of a Request for Provider Application does not guarantee privileges and/or participation at Deaconess Hospital, Inc., Evansville Surgery Center, LLC, or Deaconess Health Plans, LLC.

NOTE: MDs, DDSs, DMDs and DOs will need to complete the delineation section that appears at the bottom of the page.


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