Provider Nomination

Is there a behavioral health care provider you wish to add to the network? We would like to have him or her! 

Please complete the form below. Required fields are indicated with an asterisk (*). The required information is essential for Acentra Health, to make successful outreach to the provider.

 

  • Once the application is received, Acentra Health will begin credentialing the nominated provider, a process that takes about 90 to 120 days.
  • When the nominated provider has completed credentialing, he/she will be listed on our web site as a credentialed provider.

Nomination does not guarantee network participation.  All prospective providers undergo an extensive evaluation of their credentials and experience.  During the evaluation, Acentra Health may determine that the provider does not meet its quality standards.

Please be sure to click the submit button after completing the form.  Or if you prefer, you may print out the form and mail it to:

APS Healthcare, Inc.
PO Box 991

Brookfield, WI 53008

Attn: Provider Nomination


Or it may be faxed to 262-787-2364 attention Provider Nomination
 Provider's Information
 Provider Name:
 Provider Type:
 Provider Street Address:
 Provider City:
 Provider State:
 Provider Zip Code:
 Provider Contact Person:
 Provider Phone:
 Submitter's Information
 
 Your Company:
 Your Name:
 Your E-mail Address:
 Your Street Address:
 Your City:
 Your State:
 Your Zip Code:
 Your Phone:




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