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.

What type of provider are you? *

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

Please select an option below *

I am a Non-Contracted Provider Requesting Network Participation I Want to Add a Practitioner to an Existing Group Contract -OR- Add a Facility NPI to my Existing Facility Contract

Products Requested*

Medicaid Health Insurance Marketplace (HIM) – Ambetter Please select all the products you would like included in your Agreement

What type of facility is this? *

CMHC FQHC Hospital RHC Substance Abuse Facility

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.

Group Practice or Facility/Agency Name *

Provider First Name *

Provider Last Name *

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

Individual NPI *

Group or Facility/Agency Primary NPI *

CAQH Number *

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

Yes No

Additional NPIs * 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.

Practitioner Taxonomy *

Practitioner Medicaid #

Practitioner Medicare #

Organization Taxonomy *

Organization Medicaid #

Organization Medicare #

Correspondence Address *

City *

State *

ZIP Code *

Practice State *

Practice County *

Practice Location ZIP Code *

Contact Name *

Contact Phone *

Contact Email *

Credentialing Email *

Provider Email *

Checklist *

W9 *

Provider Specialty Profile *

Group Attestation *

Disclosure of Ownership Form *

Facility Application *

Facility Roster

Certificate of Insurance *

Additional Attachment

Additional Attachment 2 Attach licenses, accreditations, certifications, enrollment letters, etc...

Additional Attachment 3 Attach licenses, accreditations, certifications, enrollment letters, etc...

Additional Attachment 4 Attach licenses, accreditations, certifications, enrollment letters, etc...