Membership Application

Thank you for your interest in membership with Baptist Physician Partners

Once you submit an application, we will review it and reach out with any questions or concerns. If you have any additional questions please contact BPP via email at bpp@bmcjax.com. To begin, select an option below:

Is this a new application or are you adding to an existing group? (required)*

Group/Legal Entity Information

Group Information

Format: 12-3456789

Are you using a TIN that belongs to a Management Service Organization (MSO)? (required)*

Group Location

Suite, PO Box, or other address designator

Group Point of Contact

Format: 123-456-7890

Group Contract Approval Person

Format: 123-456-7890

Contract Approval Address

Suite, PO Box, or other address designator

Group/Legal Entity Lookup

Verify the group to which you are adding information by entering a valid TIN below.

Format: 12-3456789

What information do you need to add? (required)*

To add a practice, a location must be added as well.

Practice Information

Location Information

  • Location Practice & Name

    Location Phone & Fax Info

    Format: 123-456-7890
    Format: 123-456-7890

    Location EMR Info

    Location Address

    Suite, PO Box, or other address designator

    Location Office Manager Info

    Format: 123-456-7890

    Location Billing Manager Info

    Format: 123-456-7890

Provider Information

  • Provider Name & Info

    Date of Birth (required)*
    E.g. January 01, 1990
    Format: 123-456-7890

    CMS (required)*

    Provider Specialties

    Provider Practice & Locations

    Other Locations (optional)

      Medical staff privileges at a Baptist Health facility? (required)*

    Joinder Agreement

    Please note that a separate Joinder Agreement is needed for each provider. Please complete and sign the attached Aggrement and return via email to bpp@bmcjax.com or fax (904) 391-5321

    Your inclusion in BPP will become effective only after approval by the BPP Board of Managers. If approval is effective of the current year, you will not be elligible for shared savings until the next performance year.

    Please note: Locums and fellows are not accepted into Baptist Physician Partners at this time.

    Download Joinder Agreement