Affinia Health Provider Onboarding Form

Affinia Health Network Provider Onboarding

This form is to be filled out when a provider is joining an existing Affinia Health Network office. If you are inquiring about becoming a member of Affinia Health Network please visit our "Join Affinia" page.
  • Section 1- Member/Office Information:

  • Date Format: MM slash DD slash YYYY
  • Section 2- Provider Identification Information:

  • ***Please note your group is responsible for credentialing your provider(s) with each payer. If you have questions regarding this, please contact your Affinia Representative.
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