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NEW Provider/Facility Contract Request Form

Latest Provider/Facility Contract Request Form (#10)

Thank you for your interest in joining the Prime Healthcare Network. Please complete the form below, attach additional supporting documents, and return for review

Provider Information

Include the following documents for EACH individual provider:

Primary Point of Contact

PLEASE NOTE: Acceptance of a provider request form does not guarantee network participation

Please return this form along with all supporting documents to:
Prime Healthcare Management, Attention: Contracts
Email EHPprovidercontracts@primehealthcare.com or fax to 909-235-4405