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Existing Contracted Entity

Please do not use this form unless you are one of the following specialties: Diagnostic Radiology, Pathology, ER Physician, Anesthesiology (non-pain management), or CRNA. 

If you are enrolling additional specialties, please select Medical (Other) above.

Practitioner Name

Enrollment Requested By:

Practitioner Name

(i.e. hospital-based, hospitalist, etc.)
Age Restrictions*

Only One Enrollment Form Required

If enrolling in HHW, HIP and/or HCC, you must the attach MCE Universal form (PDF).
If enrolling in Ambetter or Allwell ONLY, please attach Ambetter/Allwell form (PDF).

Enrollment Requested By:

Practitioner Name

(i.e. hospital-based, hospitalist, etc.)
Age Restrictions*

Only One Enrollment Form Required

If enrolling in HHW, HIP and/or HCC, you must the attach MCE Universal form (PDF).
If enrolling in Ambetter or Allwell ONLY, please attach Ambetter/Allwell form (PDF).

Enrollment Requested By: