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Behavioral Health Contract Request Form

Solo Practitioner Contract Request

Please do not use dashes ("-")
PLEASE NOTE: Enter "Medicaid ID Pending" if you are in the process of obtaining one from DHHS

Correspondence Address

Practice Address

Contact Information & W-9 Upload

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

Group Practice Contract Request

Group Practice and Facility/Agency Contract Request

Group Practice Information

Please do not use dashes ("-")
PLEASE NOTE: Enter "Medicaid ID Pending" if you are in the process of obtaining one from DHHS

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

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

Facility/Agency Contract Request


Facility/Agency Information

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

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

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