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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.

What market are you requesting participation for? *

Error: This field is required.

What type of provider are you? *

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

Error: This field is required.

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

Error: This field is required

Products Requested*

Medicaid Health Insurance Marketplace (HIM) – Ambetter

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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

Error: This field is required.

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.

Checklist
Acceptable License Types
W-9
Provider Specialty Profile
Attestation
Supervising Physician Statement

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.

Checklist
W-9
Facility Application
Facility Roster
Hospital Attestation

Group Practice or Facility/Agency Name *

Error: This field is required.

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.

Group or Facility/Agency Primary NPI *

Error: This field is required.

CAQH Number *

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.

Practitioner Taxonomy *

Error: This field is required.

Practitioner Medicaid #

Practitioner Medicare #

Organization Taxonomy *

Error: This field is required.

Organization Medicaid #

Organization Medicare #

Correspondence Address *

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City *

Error: This field is required.

State *

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ZIP Code *

Error: This field is required.

Practice Address *

Practice State *

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Practice County *

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Practice Location ZIP Code *

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Contact Name *

Error: This field is required.

Contact Phone *

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Contact Email *

Error: This field is required.

Credentialing Email *

Error: This field is required.

Provider Email *

Error: This field is required.

Checklist *

Error: File upload is required.

W9 *

Error: File upload is required.

Provider Specialty Profile *

Error: File upload is required.

Group Attestation *

Error: File upload is required.

Disclosure of Ownership Form *

Error: File upload is required.

Facility Application *

Error: File upload is required.

Facility Roster

Certificate of Insurance *

Error: File upload is required.

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...

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