Allied Trades Assistance Program

**Already participating in-network outpatient providers are authorized to use this registration request form**

Request to join ATAP’s network: https://www.alliedtrades-online.com/provider-request-to-join-network/

Any out-of-network providers please contact us at 215-677-8820 -or- email eap@alliedtrades-online.com 

How this form works:

Please provide us with the information requested below and click submit. We will review your registration request, and you will receive an email notification to let you know if you have been approved. Once approved, you will be able to use our website to request authorizations, request re-authorizations, and check member benefits.

Register

Fields in red are required

Provider Name: Address: City: State: --- Select --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington West Virginia Wisconsin Wyoming Zip: Main phone: Mobile: Fax: Tax ID #: Email Address: Password: (Password must be minimum 6 characters with a number & symbol.) Preferred Method to Contact:
Phone Fax Email

Notes:

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