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Contracted Enrollment Request

  • This request is for practitioners that have one of the following primary specialties. If you have a different specialty than listed below please direct your enrollment request to Contracted Enrollment Request - Medical or BH form.
    • Anesthesiology (non pain management)
    • CRNA
    • Diagnostic Radiology
    • ER Physician
    • Pathology
  • Your participating enrollment will not appear in our directory.
  • Your participating enrollment will not require credentialing.
  • You participating enrollment will be limited to 1 location per TIN/GNPI.
Please select the programs you wish to participate in required*

Provider/Facility Information

*1 GNPI per request
*not applicable for Commercial Programs
*i.e. Clinic, Hospital, Group Practice, etc.

Practitioner Information

*not applicable for Commercial Programs
Last Updated: 09/09/2022