Contract Request Form

Thank you for your interest in joining our Louisiana Healthcare Connections Medicaid network. Please complete the form below, and our contracting team will reach out to you.

For contracting interest in our Marketplace network, please visit our Ambetter from Louisiana Healthcare Connections website.

For contracting interest in our Medicare network, please visit our Wellcare website.

Required fields are marked with an asterisk (*)

First Name *

Last Name *

Contact Phone Number *

Contact E-Mail Address *

Provider Information

Legal Entity Name *

ATTN: *

Street Address *

Address Line 2

City *

State *

ZIP Code *

Provider Identification Numbers

Tax ID *

Group NPI *

Medicaid Number

Will you function as a Primary Care Physician (PCP)? Yes No

If you chose other, what type of provider are you?

Which products would you like to participate in? * Medicaid (Healthy Louisiana)