Skip to Main Content

search

Home
Find a Provider
Login
Careers
Contact
Find Community Resources

Contrast On Off

a a a

English
Spanish
Français
中文
नेपाली
Tiếng Việt
Português
Eλληνικά
العربية
Српски
Bahasa Indonesia
한국어
Русский язык
Kreyòl
Bantu
Polski
Kiswahili (Swahili)

For Members show For Members submenu
- Health Insurance Marketplace Plan
- Medicaid Plan
For Providers show For Providers submenu
Get Insured

MENU

SEARCH

search

English
Spanish
Français
中文
नेपाली
Tiếng Việt
Português
Eλληνικά
العربية
Српски
Bahasa Indonesia
한국어
Русский язык
Kreyòl
Bantu
Polski
Kiswahili (Swahili)

Home
Find a Provider
Login
Careers
Contact
Find Community Resources

Login
Find a Doctor
For Members
- Health Insurance Marketplace Plan
- Medicaid Plan
For Providers
Get Insured
About Us
Contact Us
- Phone Directory
Newsroom
Events
Privacy Policy
Terms & Conditions
Notice of Privacy Practices

For Providers
Create Your Account
Become a Provider
Pre-Auth Check
- Ambetter Pre-Auth
- Medicaid Pre-Auth
Pharmacy
Provider Resources
QI Program
Provider News
Coronavirus Information for Providers
Provider Contact Information Submission

Behavioral Health Contract Request Form

What type of provider are you? *

Solo (if you are the only practitioner billing with your own Tax ID#) Group Practice Facility/Agency Group Practice and Facility/Agency

Error: This field is required.

Solo Practitioner Contract Request

Provider First Name *

Error: This field is required.

Provider Last Name *

Error: This field is required.

Tax ID *

Error: This field is required.

Please do not use dashes ("-")

Individual NPI *

Error: This field is required.

Medicaid Number *

Error: This field is required.

PLEASE NOTE: Enter "Medicaid ID Pending" if you are in the process of obtaining one from DHHS

Practitioner Taxonomy *

Error: This field is required.

Correspondence Address

Correspondence Address *

Error: This field is required.

City *

Error: This field is required.

State *

Error: This field is required.

Zip Code *

Error: This field is required.

Practice Address

Practice Address *

Error: This field is required.

State *

Error: This field is required.

County *

Error: This field is required.

Zip Code *

Error: This field is required.

Contact Information & W-9 Upload

Contact Name *

Error: This field is required.

Contact Phone *

Error: This field is required.

Contact Email *

Error: This field is required.

Provider Email *

Error: This field is required.

W-9 Upload *

Error: File upload is required.

Please upload a completed, signed, and dated W-9 form.

Group Practice Contract Request

Group Practice and Facility/Agency Contract Request

Group Practice Information

Group Practice Name *

Error: This field is required.

Group Practice Tax ID *

Error: This field is required.

Please do not use dashes ("-")

Group Practice Primary NPI *

Error: This field is required.

Group Practice Medicaid Number *

Error: This field is required.

PLEASE NOTE: Enter "Medicaid ID Pending" if you are in the process of obtaining one from DHHS

Group Practice Organization Taxonomy *

Error: This field is required.

Group Practice Correspondence Address

Group Practice Correspondence Address

Correspondence Address *

Error: This field is required.

City *

Error: This field is required.

State *

Error: This field is required.

Zip Code *

Error: This field is required.

Group Practice Address

Group Practice Address

Practice Address *

Error: This field is required.

City *

Error: This field is required.

State *

Error: This field is required.

County *

Error: This field is required.

Zip Code *

Error: This field is required.

Group Practice Contact Information & W-9 Upload

Group Practice Contact Information & W-9 Upload

Contact Name *

Error: This field is required.

Contact Email *

Error: This field is required.

Contact Phone *

Error: This field is required.

Provider Email *

Error: This field is required.

W-9 Upload *

Error: File upload is required.

Please upload a completed, signed, and dated W-9 form.

Facility/Agency Contract Request

Facility/Agency Information

What type of facility is this? *

CMHC FQHC Hospital RHC Substance Abuse Facility

Error: This field is required.

Facility/Agency Name *

Error: This field is required.

Facility/Agency Tax ID *

Error: This field is required.

Please do not use dashes ("-")

Facility/Agency Primary NPI *

Error: This field is required.

Does your Organization have multiple Facility/Agency NPIs on this application? *

Yes No

Error: This field is required.

Additional NPIs *

Error: This field is required.

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.

Facility/Agency Medicaid Number *

Error: This field is required.

PLEASE NOTE: Enter "Medicaid ID Pending" if you are in the process of obtaining one from DHHS

Facility/Agency Organization Taxonomy *

Error: This field is required.

Facility/Agency Correspondence Address

Facility/Agency Correspondence Address

Correspondence Address *

Error: This field is required.

City *

Error: This field is required.

State *

Error: This field is required.

Zip Code *

Error: This field is required.

Facility/Agency Practice Address

Facility/Agency Practice Address

Practice Address *

Error: This field is required.

State *

Error: This field is required.

County *

Error: This field is required.

Zip Code *

Error: This field is required.

Facility/Agency Contact Information & W-9 Upload

Facility/Agency Contact Information & W-9 Upload

Contact Name *

Error: This field is required.

Contact Email *

Error: This field is required.

Contact Phone *

Error: This field is required.

Provider Email *

Error: This field is required.

W-9 Upload *

Error: File upload is required.

Please upload a completed, signed, and dated W-9 form.

Are you currently contracted with WellCare? *

Yes No Unsure

Error: This field is required.

Estimate the number of practitioners you wish to enroll: *

Error: This field is required.

Home
Events
Newsroom
About Us
Contact Us

Careers
Privacy Policy
Notice of Privacy Practices
Terms & Conditions
Language Assistance
Statement of Non-Discrimination
Site Map

You will need Adobe Reader to open PDFs on this site.

Download the free version of Adobe Reader.

You will need Adobe Reader to open PDFs on this site.

Download the free version of Adobe Reader.

Member and Provider Services:
1-866-769-3085

© Copyright 2021 Centene Corporation. New Hampshire Healthy Families is underwritten by Granite State Health Plan, Inc.