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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., Evansville Surgery Center, LLC, The Heart Hospital at Deaconess Gateway, 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, Evansville Surgery Center, and The Heart Hospital at Deaconess Gateway, LLC 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
  • The Heart Hospital at Deaconess Gateway, LLC – 812-842-4784

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:
Secondary 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 Mailing 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., The Heart Hospital at Deaconess Gateway, LLC, 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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