Provider Contract Request Form

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.

*
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

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

Provider Information

*
Please fill legal entity name.
*

(If additional locations please attach roster)

Please fill business/service address.
*
Please fill business city.
*
Please fill County.
*
Please fill business state.
*
Please fill zip Code.
*
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.
*
Please fill zip Code.

Provider Identification

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

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

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