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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

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Solo Practitioner Contract Request

Provider First Name *

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Provider Last Name *

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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 *

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City *

Error: This field is required.

State *

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Zip Code *

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Practice Address

Practice Address *

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State *

Error: This field is required.

County *

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Zip Code *

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Contact Information & W-9 Upload

Contact Name *

Error: This field is required.

Contact Phone *

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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

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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.

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