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)
- Diagnostic Radiology
- ER Physician
- 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.