Get Molina Contract Request Form

Filling out the Molina Contract Request Form online is an important step in initiating your request to become a provider in the WellSense Provider Network. This guide provides a detailed, step-by-step approach to completing the form accurately and effectively.

Follow the steps to complete the Molina Contract Request Form online.

1. Click the ‘Get Form’ button to obtain the Molina Contract Request Form and open it in your online editor.
2. In the first section, indicate with an X whether you are submitting the request with interest in participating with WellSense Health Plan for either MA or NH.
3. Please provide your provider name (doing business as) and legal name as it appears on your W9 in the designated fields.
4. Enter your Tax ID number. Remember to attach your W-9 with the request.
5. Fill in your primary practice address and billing address. If you have additional locations, include those on a separate sheet.
6. Provide your phone and fax numbers for both your practice and billing offices.
7. Enter the office manager's name and email address, as this information is required for communication.
8. Fill out the credentialing contact information, including their name, email, address, and phone number.
9. Provide the legal notices and mailing address for your Chief Financial Officer (CFO) or other Provider Contracting contact, ensuring all required fields are completed.
10. If applicable, list all providers in a group request, including their specialties and hospital affiliations.
11. Indicate the population served and ages served, if relevant, and provide any special services offered by the provider.
12. Confirm Medicaid approval by checking the relevant boxes for NH and MassHealth, and include any required identification numbers.
13. Specify the type of agreement requested and ensure your W-9 and Tax ID correspond with your selections.
14. Review all entered information for accuracy. Once completed, save your changes and download or print the form if necessary.
15. Submit your completed form and W-9 to the appropriate email address, either for Massachusetts or New Hampshire, as specified on the form.

Begin filling out your Molina Contract Request Form online today to take the first step towards becoming a provider.