Become a Contracted Provider

Which lines of business do you want to contract with? *

Medicaid Medicare Ambetter MI Health Link

Specialty *

Provider TIN *

Group NPI *

State License Number *

License Issuing State *

State License Expiration Date * Please enter date in (MM/DD/YYYY) format

Name *

Legal Name *

Contact Name *

Contact Phone *

Contact Email *

Are you submitting for a Provider, Facility, or both? *

Provider Facility Provider and Facility

Upload Completed Provider Credentialing Application *

Upload Completed Facility Credentialing Application *

Upload Completed W9 Form *

Upload Completed MI Meridian Disclosure Form *

Upload Completed Physician Roster