Facilities, Professional Groups, & Ancillary Providers
This form may be used to request contracting, credentialing, and to add a new tax ID to your contract.
If you are a PT/ST/OT professional and are part of a group, your group must have a group contract on file with us before we can complete your credentialing. To request a group contract, see the above facility/group form.
Providers with Concierge Practices
Providers with concierge practices must meet specific requirements and sign a Concierge Practice Contract Addendum. For more information, reach out to your Provider Relations Contact.