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Become a Contracted Provider

Please complete all fields on this form and attach all required credentialing and enrollment documents. Any incomplete requests will be denied.

Contract Products*
certify_CAQH_profile_is_up_to_date*

Be sure:

  • Your document expiration dates are no more than 30 days from the date of request to avoid documents expiring during the credentialing process.
  • You are not missing any required CAQH documents.
  • You do not have any errors in your CAQH profile.
The following information is required in your CAQH profile for credentialing:
  • Medical Liceanse
  • DEA/CDS Certificate (if applicable)
  • Medicaid Number (if requesting Medicaid participation)
  • Medicare Number (if requesting Medicare participation)
  • Board Certification
  • Specialties
  • Liability Insurance
  • Practice Location Information
  • Professional Training
  • Admitting Privileges
  • Hospital Affiliations
  • Credentialing Contact

Required for Provider (Practitioner/Group) Credentialing/Enrollment

(* denotes additional required BH Forms, if applicable)

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.

Collaborative Agreement (required for NP/PA/CNS)

W-9

Please complete all fields on this form and attach all required credentialing and enrollment documents. Any incomplete requests will be denied.

Contract Products*

Required for Ancillary Providers

(* denotes additional required BH Forms, if applicable)

Provider Location Listing (only Location Listing tab required for Ancillary requests)

Accreditation Certificate

(required for ancillary provider only)

Copy of Medicaid Certification Letter

Copy of Medicare Certification Letter

Liability Coverage

CLIA Certificate

W-9

Please complete all fields on this form and attach all required credentialing and enrollment documents. Any incomplete requests will be denied.

Contract_Products*

W-9

To enroll a new provider to your existing contract, use the Contract Enrollment Request form.

Last Updated: 05/25/2022