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Provider Relations
513-551-1440

Completed Applications should include
Current State Medical License.
Copy of Board Certification.
Your DEA or State license of controlled substances.
Professional Liability declaration page.
Completed malpractice claims information within last 10 years.
Curriculum Vitae, which includes work history dates.
Signed W-9 or Tax I.D. verification.
Two professional peer references, if not Board Certified.
Residency or Fellowship certificates.
List of all office locations.
List of all hospital affiliations.
Remittance address.
Any written explanations requested on the application.

Participate in Our Network

Thank you for your interest in HealthSpan, the largest provider-sponsored PPO in the Greater Cincinnati / Tristate region. You may request an Application Packet. These packets are available in portable document format (PDF) for download, but must be manually completed and mailed to HealthSpan for review. You may contact HealthSpan at 513-551-1440 to obtain a Participating Service Agreement after you have completed and mailed your application for participation in our network.

Include all information requested and mail your completed packet to:

    HealthSpan, Inc.
    Provider Relations
    Pictoria Tower I
    225 Pictoria Drive, Suite 320
    Cincinnati, OH 45246

HealthSpan will review your application against specific standards for participation in addition to the American Accreditation Commission/URAC standards. Sending in an application does not automatically make you a HealthSpan network provider. We will contact you regarding your participation status. Or, you may contact Provider Relations at 513-551-1440.

Application Downloads

Download the appropriate PDF Network Participation Application Form below, then mail your completed application to HealthSpan.

Physician Application
Chiropractor Application
Behavioral Health Application
Ancillary Services Application


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