ITEMS IN BOLD ARE REQUIRED FIELDS

First Name:
Last Name:
Degree:
Specialty:
NPI:
Group:
Office Address:
Address Line 2:
City:
State:
Zip:
Phone Number:
Fax Number:
  (include area code)
Email Address:
Hospital(s):
  (hold Ctrl and click to select multiple hospitals)
Questions:
 

INSTRUCTIONS
Thank you for your interest in an EA Health On-Call Program. If you are a physician that provides care at an EA contracted hospital, and would like to receive an EA Physician Services Agreement, please fill out and submit the form. Pending hospital administrative approval, your contract will be sent to the email address given.

If your hospital is not included in the list, or you have any questions, please call EA Health Provider Enrollment at 866.303.2262 option 3.

Thank you.