* = required field
Thank you for your interest in becoming a Molina Healthcare Provider.
To ensure the proper contract and credentialing packet is generated; please complete this contract request form.
(*) Indicates a required field.
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.
(If additional locations please attach roster)
(Contract will be emailed)
(*note: cannot create group contract if no group Medicaid)
Once completed form is submitted, please allow 5-7 business days for contract packet to be e-mailed. Included in the contract package will be an opportunity to provide us with more details about your office. Requests to status application can be e-mailed to MHMProviderContractingMailbox@Molinahealthcare.com
Thank you for your interest in Molina Healthcare of Michigan. Your inquiry is being reviewed and will be assigned to a provider contracting specialist who will help fulfill your request in 5-7 days