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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 (*)

Provider Information

Provider Identification Numbers

Will you function as a Primary Care Physician (PCP)?
Which products would you like to participate in? required *