Skip to Main Content

Contracted Enrollment Request - Medical or BH

Are you a Provider or Practitioner? *
Do you wish to enroll in Medicaid? (HCC, HHW, HIP)
Please select the programs you wish to participate in required *

Please select the applicable program and provider type you wish to participate in

Wellcare by Allwell & Wellcare Complete

Provider/Facility Information

*not applicable for Commercial Programs

Practitioner Information

Do you offer Telehealth Appointment? *
Are you providing Behavioral Services? *

Member/Panel Size on IHCP/Ambetter/Wellcare by Allwell/Wellcare Complete 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.

Required Document Attachments

(* denotes additional required BH Forms, if applicable)

Please complete the provider forms below.

Provider Credentialing Form (PDF)

If there are 10 or more practitioners to be enrolled with a group contract request, please utilize the Practitioner Enrollment Spreadsheet.

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

Accreditation Certificate

(required for ancillary provider only)

Copy of Medicaid Certification Letter

Liability Coverage

CLIA Certificate


Required Document Attachments

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)

Required Document Attachments

If you requesting Commercial only programs complete the Ambetter/Wellcare by Allwell/Wellcare Complete PDF enrollment form.

Ambetter & Wellcare by Allwell Provider Enrollment Form (PDF)

Supplemental Document Attachments

The following documents are required depending on your specialty.

A Collaborative Agreement is required for the following Physician (Practitioner) types:

  • Nurse Practitioners
  • Physician Assistants
  • Midwives
  • Clinical Nurse Specialists

If you are a Behavioral Health Practitioner this form should be completed.

Behavioral Health Specialty Profile (PDF)

Last Updated: 04/26/2024