- Respond to ALL applicable fields displayed on this form. Failure to provide requested information will delay and / or prevent your request from being processed.
Please be aware, if additional information is needed, Advocate Physician Partners will contact you.
- The following Change types apply to Provider Practice Demographics such as Practice location, Billing information, Office Hours, Office Phone Numbers, etc.:
ADD (NEW information only)
CHANGE (Update CURRENT to NEW information)
REMOVE (CURRENT information only)
The following Change Types apply to Network Participation Status:
Resign (Provider is exiting one or more PHOs)
Leave of Absence (Provider is requesting leave from patient care in the network)
The following Change Types apply to the Provider Network Profile:
Provider Name Change (must match Illinois State Medical/Professional License)
Provider Practicing Specialty Change
Primary PHO Affiliation Change
Only one type of request is permitted per submission.
Please Note: Requests submitted will only apply to currently active Advocate Physician Partners providers.
Select all that apply. To Select multiple Location / Information Types:Windows computers users - press and hold the Control [Ctrl] button while making selections. Apple computers users - press and hold the Shift button while making selections.
- If you are ADDING or REMOVING a Provider / Providers to your Practice Tax ID, be sure include "Billing/Payment Information" under the Location / Information Types.
Please provide a description of what is being requested.
Effective Date cannot be more than 90 days retroactive from today's date.
Date Format: MM slash DD slash YYYY
- Provider Name Change requests can only be submitted for One Provider per request.
Only include providers who are actively affiliated with Advocate Physician Partners.
Resignation Details
Select the PHO(s) that should remain ACTIVE.
If applicable
A mailing address is requested for any solo practitioners who are fully exiting the APP Network.
Advanced Practice Providers includes Nurse Practitioners, Physician Assistants, Clinical Nurse Specialists, etc.
Specialty Information
For providers currently on staff at an Advocate Health hospital, the specialty requested below must be in alignment with the specialty provided to the Medical Staff Office.
- If you are submitting multiple providers on this request, the Summary of Provider Role, Practice Limitations, and Clinical Focus/Areas of Interest will be applied to each provider listed. If the role, limitation, and focus/areas will be different by provider, please submit a separate form for each.
Provide a brief description of how / where this provider will practice. Examples: covers call only, ambulatory / outpatient only, etc.
Select all practice limitations that apply, if any. If no limitations apply, then select "No limitations".
A minimum of 1 Clinical Focus / Areas of Interest must be provided. You may add up to 5 areas of Clinical Focus/Interest.
Leave of Absence Details
Advocate Physician Partners will review your request and provide confirmation, if approved. If your request is not approved, we will follow-up regarding the denial.
- Leave of Absence requests will be processed for ALL currently active Advocate Physician Partners PHO affiliations. Providers may request up to 12 months of leave from the Network.
Please provide details for requested Leave of Absence.
Date Format: MM slash DD slash YYYY
Date Format: MM slash DD slash YYYY
Provide the Full Name and Degree of the Advocate Physician Partners Physician who will provide coverage during the Leave of Absence.
Advanced Practice Providers includes Nurse Practitioners, Physician Assistants, Clinical Nurse Specialists, etc.
Provider Name Change Details
- Advocate Physician Partners may reach out to you to obtain a copy of the Provider's Illinois State Medical / Professional License.
The NEW name must exactly match the Illinois State Medical/Professional License.
Provider Primary PHO Affiliation Updates
- Provider(s) MUST be currently Active with the NEW Primary PHO being requested.
If you would like the provider(s) to join a new Primary PHO, please reach out to the Provider Relations team. Current Location Information
- Clinical Practice Location / Site of Care
Clinical Practice Location/Place of Service
Indicate whether Current Practice should become Primary or Secondary.
- Which Address should become Primary?
Providers should already be linked to this New Primary Practice Name and Address. If the providers are not currently linked, please submit an ADD (NEW Information only) request. -
NEW Location Information
Clinical Practice Location/Site of Care
- Note: If your practice location is new to the Advocate Physician Partners network, you will be required to complete the Practice Location Accessibility Survey
Clinical Practice Location/Place of Service
Clinical Laboratory Amendments Certifications. If No CLIA number, please type EXEMPT.
IF No CLIA Number, please type EXEMPT.
Please list all Foreign languages separated by commas.
NEW Location Hours - Clinical Site of Care
What are the Hours of Operation at this Location? Office Hours are defined as times when Clinical Staff are present to treat patients.
Please note: The hours provided should NOT be specific to one provider and should apply for the location as a whole.
Current Billing Information
List Tax ID Legal Owner name, including SC, LLC, Ltd, etc. as applicable. Should match Line 1 of your group's W9 form.
List Group Billing Name, if different than Tax ID Legal Owner Name.
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W9 Address should reflect where Tax related communications are to be mailed. Payment Address should reflect where Payments are to be mailed.
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Billing Information - NEW
If your Practice Group will be new to the Advocate Physician Partners network, you will be required to complete the APP Practice Group Survey
List Tax ID Legal Owner name, including SC, LLC, Ltd, etc. as applicable. Should match Line 1 of your group's W9 form.
List Group Billing Name, if different than Tax ID Legal Owner Name.
-
W9 Address should reflect where Tax related communications are to be mailed. Payment Address should reflect where Payments are to be mailed.
W9 Details - NEW
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W9 Information
A copy of the Federal W9 form must be uploaded if: you are adding a new provider to your Tax ID, you are establishing a new Tax ID, or you are making changes to your Billing Information or Group Name. The W9 form must be signed and dated or it will not be accepted for processing.
