Items in the trash will be permanently removed after 30 days.
Please complete all fields on this form and attach all required credentialing and enrollment documents. Any incomplete requests will be denied.
Please enroll in IHCP here
The following information is required in your CAQH profile for credentialing:
IHCP MCE Practitioner Enrollment Form (PDF)
If there are 10 or more practitioners to be enrolled with a group contract request, please utilize the Practitioner Enrollment Spreadsheet.
*Behavior Health & Ancillary Provider Specialty Form (PDF)
Ambetter & Wellcare by Allwell Provider Enrollment Form (PDF)
Provider Location Listing Spreadsheet
Collaborative Agreement (required for NP/PA/CNS)
Provider Credentialing Disability Form (required for all Medical requests) (PDF)
HSPP Attestation (BH Only) (PDF)
Provider Location Listing (only Location Listing tab required for Ancillary requests)
IHCP MCE Hospital/Ancillary Provider Enrollment and Credentialing Form (PDF)
BH Facility and Ancillary Demographic Info* (PDF)
Provider Location Listing
To enroll a new provider to your existing contract, use the Contract Enrollment Request form.