Molina Healthcare of Michigan Provider Contract Request Form

Thank you for your interest in becoming a Molina Healthcare of Michigan Provider. To ensure the proper contract and credentialing packet is generated; please complete this contract request form. (Michigan providers only)

(*) Indicates a required field.

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Please select provider type.

If you are adding providers to a participating group or PHO/PO, please submit a Provider Addition Roster to MHMContractConfigDept@Molinahealthcare.com. For questions, please call the Provider Call Center at (855) 322-4077. Requests for provider additions on this template will not be processed.

Contact Information

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Please Fill Requester Name.
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Please fill requestor phone ( E.g (xxx)-xxx-xxxxx ).Please fill a valid phone number e.g. (xxx) xxx-xxxx
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Please fill requestor email.Please enter a valid email address

Provider Information

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Please fill legal entity name.
*

(If additional locations please attach roster)

Please fill business/service address.
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Please fill business city.
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Please fill County.
*
Please fill business state.
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Please fill zip Code.
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Please fill office phone ( E.g (xxx)-xxx-xxxxx ).Please fill a valid office phone number e.g. (xxx) xxx-xxxx
*
Please fill requestor email.Please enter a valid email address
*

(Contract will be emailed)

Please fill mailing address.
*
Please fill city.
*
Please fill state.
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Please fill zip Code.

Provider Identification

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Please select for providers applying as
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Please fill specialty.
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Please fill tax ID.
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Please fill degree type.
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Please fill group NPI.
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Please fill individual NPI.
*

(*note: cannot create group contract if no group Medicaid)

*
Please fill hospital affiliation(s).
Please select captcha