Contract Request Form

Required fields are marked with an asterisk (*)

First Name *

Last Name *

Contact Phone Number *

Contact E-Mail Address *

Provider Type

Legal Entity Name *

ATTN: *

Street Address *

Address Line 2

City *

State *

ZIP Code *

Tax ID *

Group NPI *

Medicaid Number

Will you function as a Primary Care Physician (PCP)?

Yes No

Type of Provider (please select one)

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

Which products would you like to participate in?*

Medicare Advantage Medicaid (Healthy Louisiana)

This field is for validation purposes and should be left unchanged.