Molina Healthcare of Michigan Provider Contract Request Form

Thank you for your interest in becoming a Molina Healthcare of Michigan Provider. To ensure the proper contract and credentialing packet is generated; please complete this contract request form. (Michigan providers only)

(*) Indicates a required field.

Please Select Provider Type*

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

Requester Name:*

Please Fill Requester Name.

Requestor Phone*

Please fill requestor phone ( E.g (xxx)-xxx-xxxxx ).Please fill a valid phone number e.g. (xxx) xxx-xxxx

Requestor Email*

Please fill requestor email.Please enter a valid email address

Requester Fax

Provider Information

Legal Entity Name*

Please fill legal entity name.

Business/Service Address*

(If additional locations please attach roster)

Please fill business/service address.

City*

Please fill business city.

County*

Please fill County.

State*

Please fill business state.

Zip*

Please fill zip Code.

Office Phone*

Please fill office phone ( E.g (xxx)-xxx-xxxxx ).Please fill a valid office phone number e.g. (xxx) xxx-xxxx

Office Fax

Office Email*

Please fill requestor email.Please enter a valid email address

Mailing Address*

(Contract will be emailed)

Please fill mailing address.

City*

Please fill city.

State*

Please fill state.

Zip*

Please fill zip Code.

Provider Identification

For Providers applying as:*

Primary Care Provider Specialist Behavioral Health

Please select for providers applying as

Specialty*

Please fill specialty.

Tax ID*

Please fill tax ID.

Degree Type*

Please fill degree type.

Group NPI*

Please fill group NPI.

Group NPI applies to all providers using this Tax ID Group NPI applies to all service locations using this Tax ID

Individual NPI*

Please fill individual NPI.

Is your organization and all of your providers enrolled in CHAMPS?*

Yes No

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

Hospital Affiliation(s):*

Please fill hospital affiliation(s).

Please select captcha

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

By submitting my information via this form, I consent to having Molina Healthcare collect my personal information. I understand and agree that my information will be used and shared in accordance with Molina Healthcare's Privacy Policy and Terms of Use.

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Molina Healthcare of Michigan Provider Contract Request Form

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