Get Non-par Provider Contract Request Form

Filling out the Non-Par Provider Contract Request Form is an essential step for providers looking to join Molina Healthcare's network. This guide provides clear, step-by-step instructions to help you successfully complete the form online.

Follow the steps to easily complete the form online.

1. Click the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Enter your provider name in the designated field. Ensure that this is the name under which you operate.
3. In the following field, input your practice name. If you are part of a medical group, please include a roster with the names and specialties of all practitioners within the group.
4. Select your provider type and specialty from the options provided. Accurately stating this information is crucial for the contracting process.
5. Provide your Medicaid ID number in the relevant field.
6. Enter your Provider Tax Identification Number (TIN) and your National Provider Identifier (NPI).
7. Fill in your mailing address thoroughly to ensure correspondence is sent to the right location.
8. If your primary office location differs from your mailing address, please include that information in the next field.
9. Identify the contact person and their title within your practice. This person will be the primary contact for Molina Healthcare.
10. Provide a phone number where you can be reached easily and enter your county.
11. Input your email address for further communication regarding your application.
12. Indicate whether all practitioners are employed physicians of your group by selecting 'Yes' or 'No.'
13. Once all fields are accurately filled out, ensure you include a current copy of your W-9 form. Save your changes before finalizing the document.
14. At this point, you have options to download, print, or share the completed form based on your preferences.

Complete the Non-Par Provider Contract Request Form online today to begin your journey with Molina Healthcare.