Provider Referral Service Application

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* Provider Name

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* National Provider Identifier (NPI)

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* Primary Office Information

Practice Name

Address

City

State

Zip Code

Phone Number

Fax Number

Practice Website

Office Hours

Office Manager Name

Office Manager Email Address

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* Secondary Office Information

Practice Name

Address

City

State

Zip Code

Phone Number

Fax Number

Practice Website

Office Hours

Office Manager Name

Office Manager Email Address

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* The primary contact for your office will be granted access to request updates to parts of your online profile. The primary contact is typically your practice manager or office coordinator, and they will have access to all the providers at your practice.

Please provide the full name and email address for the primary contact for your office.

Name

Email Address

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* Are you employed by or serve in an administrative or leadership role at another hospital outside of Beaumont Health?

Yes

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* Are you offering telehealth visits for new patients?

Yes

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* What age groups are seen in the practice? Please select all that apply.

Newborns

Pediatrics

Teenagers

Adults

Geriatrics

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* Select insurance plans that are accepted for new patient visits. In the future, please notify PRS of any changes to insurance enrollment.

Aetna - PPO, POS

Aetna - Medicare Advantage

Aetna Better Health of Michigan - Medicaid

Ambetter - Marketplace (Various Metal Products)

AmeriHealth - MI Health Link

Apostrophe

Auto Insurance

BCBSM - Blue Cross Complete - Medicaid

BCBSM - Marketplace (Various Metal Products)

BCBSM - Marketplace - EPO

BCBSM - Medicare Advantage

BCBSM - PPO

BCBSM - Traditional

BCN - HMO, POS

BCN - Marketplace (Various Metal Products)

BCN - Marketplace - Metro Detroit

BCN - Medicare Advantage

Beechstreet - PPO

Cash/Credit Cards

Cigna Preferred HAP - EPO, POS, PPO

Cofinity

HAP - HMO

HAP - Marketplace (Various Products)

HAP AHLIC - EPO, POS, PPO

HAP Alliance - Marketplace (Various Products)

HAP Alliance - Medicare Advantage

HAP Empowered - Medicaid

HAP Empowered - MI Health Link

HAP Senior Plus - Medicare Advantage

Humana - Medicare Advantage

McLaren Health Plan - HMO, POS

McLaren Health Plan - Marketplace (Various Metal Products)

McLaren Health Plan - Medicaid

McLaren Health Plan - Medicare Advantage

Medicaid

Medicare

Meridian Health Plan - Medicaid

Molina Healthcare - Marketplace (Various Metal Products)

Molina Healthcare - Medicaid

Molina Healthcare - Medicare Advantage

Molina Healthcare - MI Health Link

Multiplan - POS, PPO

Priority Health - HMO

Priority Health - Marketplace (Various Metal Products)

Priority Health - Medicaid

Priority Health - Medicare Advantage

Priority Health - PPO

Three Rivers

Tricare (Champus)

United Healthcare - EPO, POS, PPO

United Healthcare - HMO

United Healthcare - Marketplace - Core & Compass

United Healthcare - Medicaid

United Healthcare - Medicare Advantage

Wellcare - Medicare Advantage

Worker's Compensation

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* Beaumont Accountable Care Organization

Providers interested in joining PRS must participate in Beaumont Accountable Care Organization (BACO)

A physician and Beaumont Health system partnership

Positions members to maximize clinical value, payor contracts and incentive opportunities

No enrollment cost or annual participation fees

The provider network for the Beaumont Employee Health Plan

This beneficial physician-lead organization is one of the nation’s top performing ACOs. Founded on trust, transparency and physician leadership, the ACO offers participation in several value-based programs and offers the ability to contract with all major health plan in Southeast Michigan.

To join, or for more information, please email, ACOProviderRelations@beaumont.org or visit www.beaumont-aco.org

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* Request A Physician Appointment

One feature of the referral service is that patients can submit an online form requesting an appointment with you. Patient self-referrals will be sent through secure email directly into your mailbox within the minute that a patient requests to schedule. As emails are forwarded to your inbox, please respond to patients’ requests within two business days. You can update the email in Beaumont's Physician Preference Guide.

Please enter the email you would like the self-referrals to be sent to.

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* Additional profile enhancement opportunities and contact information

Photo

schedule an appointment: beaumontprofilescheduling.as.me

Video

schedule an appointment: beaumontprofilescheduling.as.me

Professional Statement and Curriculum Vitae (CV)

send completed professional statement or CV to PRS@beaumont.org

Practice Website URL

send URL to PRS@beaumont.org

Any other questions, please contact PRS@beaumont.org