Contracted Enrollment Request

Please select the programs you wish to participate in *

Medicaid Medicare Ambetter MI Health Link

Provider/Facility Information

Group/Facility Name *

Billing Tax ID (TIN) *

Group/Facility Billing NPI (Type 2) *

Primary Physical Location Address, City, State, Zip *

Location Appointment Phone Number *

Group/Facility Specialty * *i.e. Clinic, Hospital, Group Practice, etc.

Location Fax Number *

Is the Provider/Facility a Minority-owned or controlled agencies and organizations? *

Yes No

Practitioner Full Name *

Practitioner NPI (Type 1) *

Practitioner Primary Specialty

Practitioner Primary Taxonomy

Requestor Full Name *

Requestor Phone Number for Questions *

Requestor Email Contact for Questions *