PHO Application Forms

Thank you for your interest in the Manatee Physician Hospital Organization (PHO). Please review the PHO's Bylaws to understand the PHO's organizational structure and authority, the Physician Master Participation Agreement to understand your obligations as a participating physician and the Product Specification Standards which defines contract terms and conditions desired by the PHO.

Download and complete the application forms below. Please ensure that all areas and signatures are complete, and submit the required documents to:

Christine Culver, PHO Coordinator
Manatee Memorial Hospital
206 Second Street East
Bradenton, FL 34208

If you have any questions about the application process, please call Christine Culver at (941) 745-6889.

Download print application forms:

• Customary Plan Effective Dates
• PHO Application Forms
• Humana Credentialing Application Forms
• MultiPlan/PHCS Application Forms:
  (1) Credentialing Application
  (2) Professional History and Attestation Supplement

Please keep copies for your records. You will receive notice of your effective membership data via a letter from the PHO. Payers use various methodologies to determine effective dates for participation. To check effective dates, please refer to Customary Plan Effective Dates by Payer. You will be invoiced for the new member application fee of $300 and $150 annual dues after the credentialing process is complete.