Member/Panel Size on IHCP/Ambetter/Allwell enrollment form will be applied to all contracted programs.
If you would like this panel size to vary by program please explain details in ‘Additional Comments’ field.
Please complete the provider form below.
Provider Credentialing Form (PDF)
If you requesting to participate in at least one of our Medicaid programs please complete the applicable practitioner form below (HHW, HCC, HIP).
MCE Universal form (PDF)
If you requesting Commercial only programs complete the Ambetter/Allwell PDF enrollment form.
Ambetter & Allwell Provider Enrollment Form (PDF)
The below documents are required or optional depending on your specialty and directory preferences.
Behavioral Health Specialty Profile (PDF)