Behavioral Health Contract Request Form

Provider First Name *

Provider Last Name *

Tax ID * Please do not use dashes ("-")

Individual NPI *

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

Practitioner Taxonomy *

Correspondence Address *

City *

Zip Code *

Practice Address *

County *

Zip Code *

Contact Name *

Contact Phone *

Contact Email *

Provider Email *

Group Practice Name *

Group Practice Tax ID * Please do not use dashes ("-")

Group Practice Primary NPI *

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

Group Practice Organization Taxonomy *

Correspondence Address *

City *

Zip Code *

Practice Address *

City *

County *

Zip Code *

Contact Name *

Contact Email *

Contact Phone *

Provider Email *

Facility/Agency Name *

Facility/Agency Tax ID * Please do not use dashes ("-")

Facility/Agency Primary NPI *

Facility/Agency Medicaid Number * PLEASE NOTE: Enter "Medicaid ID Pending" if you are in the process of obtaining one from DHHS

Facility/Agency Organization Taxonomy *

Correspondence Address *

City *

Zip Code *

Practice Address *

County *

Zip Code *

Contact Name *

Contact Email *

Contact Phone *

Provider Email *

Estimate the number of practitioners you wish to enroll: *

Behavioral Health Contract Request Form

Solo Practitioner Contract Request

Correspondence Address

Practice Address

Contact Information & W-9 Upload

Group Practice Contract Request

Group Practice and Facility/Agency Contract Request

Group Practice Information

Group Practice Correspondence Address

Group Practice Correspondence Address

Group Practice Address

Group Practice Address

Group Practice Contact Information & W-9 Upload

Group Practice Contact Information & W-9 Upload

Facility/Agency Contract Request

Facility/Agency Information

Facility/Agency Correspondence Address

Facility/Agency Correspondence Address

Facility/Agency Practice Address

Facility/Agency Practice Address

Facility/Agency Contact Information & W-9 Upload

Facility/Agency Contact Information & W-9 Upload