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Behavioral Health Contract Request Form

*Note: This form can not be completed without submitting a W-9 form.  Please have your W-9 ready when you begin.

Products Requested*
Please select all the products you would like included in your Agreement

Before you fill out the form below, please review the Checklist for credentialing, download all required documents, and fill them out completely. Once you have completed your documents, be sure to finish the form below and upload your documents.

Before you fill out the form below, please review the Checklist for credentialing, download all required documents, and fill them out completely. Once you have completed your documents, be sure to finish the form below and upload your documents.

Please do not use dashes ("-")
Please enter your additional Facility/Agency NPIs that you are applying for delimited by a single comma. Please do not input Individual practitioner NPIs in this field.
Attach licenses, accreditations, certifications, enrollment letters, etc...
Attach licenses, accreditations, certifications, enrollment letters, etc...
Attach licenses, accreditations, certifications, enrollment letters, etc...