In order to accurately reflect your status with our contracted payors & fellow providers, please complete or update the information below. Please remember changes may take between 30-90 days for the payors to update their records. If you have any questions, please call us at 231-672-3882.
*Last Name
*First Name
*Prof. Title
*Group, Partnership Name
*Medicare #
*Medicaid #
Please accurately reflect your status for each health plan by choosing one of the following below and noting it next to the plan.
Open: Accepting New Patients Closed: Not Accepting New or Existing Patients Existing: Accepting Existing Patients Only
Blue Care Network (HMO)
Open Close Existing
Priority Health
Aetna (PPO)
Access Health (Community Product)
BCBS-PPO/MICHILD
Health Plan of MI(M’caid)
Beechstreet (PPO)
Molina(M’caid)
Interplan Health Group
Priority Health (M’caid)
MultiPlan (PPO)
BCN (Medicare)
Physicians Care (ASR) (PPO)
Cofinity
MedAvant Healthcare/NPN (PPO)
Humana Choice Care PPO (Medicare)
Cigna
Health Alliance Plan (HAP)
BCN Medicare Advantage
Priority Health Medicare Advantage
Please list all hospital associations for this physician:
Hospital 1
Hospital 2
Hospital 3
Hospital 4
*Date of Changes
*Changes Made by
