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Contracted Enrollment Request - Medical or BH

Please select the programs you wish to participate in*

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

Provider/Facility Information

*not applicable for Commercial Programs

Practitioner Information

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.

Required Document Attachments

Please complete the provider form below.

Provider Credentialing Form (PDF)

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/Allwell PDF enrollment form.

Ambetter & Allwell Provider Enrollment Form (PDF)

Supplemental Document Attachments

The below documents are required or optional depending on your specialty and directory preferences.

  • If you are a Nurse Practitioner, Physician Assistant, Midwife or Clinical Nurse Specialist you will be required to submit a collaboration agreement or your request will be rejected and you will have to submit a new enrollment request.
  • If you are a Behavioral Health Practitioner and request your training, modalities, populations and certifications display on our member directory this form should be completed.
    • This is an optional document.

Behavioral Health Specialty Profile (PDF)

Last Updated: 08/13/2021