Medical Providers

We welcome all Providers to participate with our program.

Doctors, Nurses, Physician Assistants, etc.
Primary Care, Specialty Care, Ancillary, Biotech, Pharmaceutical,
Traditional, Alternative, or Holistic
Individual Providers, Practices or Groups, Hospital Networks

Participation begins with two simple steps

1. Complete and Submit a Provider Participation Plan

              Our Participation Plan is available here

NEW PROVIDERS Participation Plan 2015

Participation Plan 2015 Returning Providers



2. Complete and Submit a Program Referral Form

Our Referral Form is available here

2015 Referral Form[1]

        More about these Forms

Participation Plan

Form Details – The top half of Page 1 asks for information which identifies your office and contact information.  The bottom half of Page 1 is where the office chooses their level of participation based upon the number of providers in the practice.  Only one form is needed per group.  Page 2 is where your office will list the individuals providers participating in the plan.  The Participation Plan must be signed (by any authorized office representative) and dated.  The top half of Page 2 has a Providers’ List and Office Specifications Table.  This table asks for each Provider’s Name, Specialty Area, Individual Participation Level, Credentials, and License with Expiration Date.  The bottom half of Page 2 asks you for your particular office’s specifications.  Issues such as preferences to see certain diagnoses or conditions, scheduling procedures, etc. can be explained here.  The Participation Plan should be faxed to our office at 423.232.6707. 

Number of Patients – A Participation Plan details the number of AMPA approved patients a provider is willing to see during a one-year time period. AMPA approved patients might be patients referred from the provider who are determined to be eligible for the AMPA program OR AMPA approved patients who are referred from the AMPA program to the provider.  Both of these patient groups added together will equal the number of patients agreed to on the Participation Plan.

Example: Your group of four providers decides to participate for 20 AMPA patients.  During the year, your office identifies 12 patients who are uninsured and state that they lack  the ability to pay for service.  You refer those patients to our program.  AMPA assesses these patients for eligibility, finding that 8 qualify.  AMPA refers 12 patients to your office to be seen.  8 + 12 = 20



Referral Form

Part A: Provider Information – This section allows us to quickly identify who is sending us the referral and contact you should we have any questions.

Part B: Patient Demographics – This section introduces us to the patient whom you are referring.  Information includes age, date of birth, gender, address, and telephone number.  
*We need to know the Date the Patient was First Seen (attended an appointment, underwent an examination, etc.) in your Office.
*Each referral must be accompanied by Supportive Documentation. Please send any Medical Records, Office Notes, and/or relevant Diagnostics/Lab Results for the specific Diagnostics and/or Specialty areas requested. 

Part C: Diagnostic Procedure – This section is where you as the provider will indicate if you are requesting a diagnostic test.  We will need to know the level of urgency, the diagnosis, the diagnosis code, and the name of the diagnostic with any specifications.  The Referral Form also serves as an Order, so it is important that all of this information is included.

Example: Diagnosis Seizure Disorder, Diagnosis Code 345.9, Request CT w/ Contrast

Part D: Specialty Care – This section is where you as the provider will indicate if you are requesting a Specialist.  It is important that you do not list a specific provider by name, as we cannot guarantee that the patient will see him/her. You are free to list multiple specialties, but the Supportive Documentation must address each of the Specialty Areas being requested.  

                         Referral Guidelines

Our Referral Guidelines are set-up in a table containing the following columns: the particular Medical Area/Specialty, those items which are Unavailable/Out of Medical Scope for our program, the associated Limitations/Restrictions, and the Requirements for the Referral to be sent to the Specialist in question.  General Exclusions include Pain (pain of any kind will not be an acceptable primary diagnosis; it can however, be an accompanying or secondary diagnosis), Transplants, Immunizations, Bariatric Surgery, Referrals involving potential/pending lawsuits, Research and experimental treatments, Preventative services, Physicals, Obstetric Care.

Example: Area/Specialty (Gynecology), Unavailable/Out of Scope (Infertility, Sexual Dysfunction), Limitations/Restrictions (# of available providers, the patient’s county/city of residency), Requirements (If the patient has an abnormal papsmear (non-cancerous), proceed with HPV testing.  If HPV is negative, then repeat papsmear in 3 months.  Refer to Project Access after second abnormal papsmear).

Referral Guidelines are developed through the direct feedback of our providers, including individuals, groups, and the hospitals.  Your office may have specific guidelines as well.  Please share them with us, so that we can send you the most applicable patients.  You can reach us at 423.232.6700.  Choose the following extensions 101, 102, or 107…or just tell the person on the line that you need to speak with someone concerning Referral Guidelines, and she will get you to the right person.

Our Referral Guidelines are available here
Referral Guidelines

Provider Manual

To Request a Provider Manual be mailed, dropped-off, or emailed,
please call us at 423.232.6700 Ext 102 (Aubrey) or email us at

Along with our Contact Information, Forms, and Visual Aids,
the Provider Manual goes through a series of major Questions and Answers regarding the following topics:
(1) History – How did we begin?  (2) Action – What do we do and how is that different?
(3) Participation – What does it mean to accept Patients referred by the Project Access program?
(4) Participation – What is the process for referring Patients to the Project Access program?
(5) Eligibility – What qualifies a Patient for the Project Access program?
(6) Enrollment – What should Patients expect?  (7) Hospital Services  (8) Supportive Services
(9) Expanded Services  (10) Data Tracking and Reporting – Claim Forms
(11) Project Access and Cost Reduction  (12) Project Access and the Law

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