Becoming a Quest Provider

Quest Behavioral Health periodically expands its provider network to accommodate treatment needs and membership of a particular area. If you are interested in becoming a Quest provider, please complete the applicable form below and select Submit Information. You also may forward your resume to the Provider Relations Department at Quest Behavioral Health, P.O. Box 1032, York, Pa. 17405-1032. We will contact you if a need for a network expansion is identified in your practice area.

Please complete all that apply.

Private Clinician Form

Name:
Practice Address:
Phone:
What are your patient hours?
Percentage of Age Groups Treated: (check all that apply)
 0 - 5
 6 - 12
 13 - 17
 18 - 64
 65+
Please list any clinical specialty areas, disorders, or cultural groups you treat.
Are you licensed in the State of Pennsylvania? Yes  No

Group Practice Form

Group Name:
Practice Address:
Phone:
Contact Person:
What services do you offer?
What are your patient care hours?
How many clinicians do you have in your group?
How many are licensed in
the State of Pennsylvania?
Percentage of Age Groups Treated: (check all that apply)
 0 - 5
 6 - 12
 13 - 17
 18 - 64
 65+
Please list any clinical specialty areas, disorders, or cultural groups you treat.

Facility Form

Facility Name:
Facility Address:
Phone:
Contact Person:
What services do you offer?
Do you have other sites? Yes  No
Please list location/address:
Services offered at alternate site:
Percentage of Age Groups Treated: (check all that apply)
 0 - 5
 6 - 12
 13 - 17
 18 - 64
 65+
Please list any clinical specialty areas, disorders, or cultural groups you treat.


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