Become a Provider Intake Form

Join our Network

Thank you for your interest in participating with Coordinated Care. We are excited that you selected our provider network as your network of choice.

Please fill out the Provider Intake Form below in order for us to have a better understanding of what services you provide, your location, as well as pertinent information needed for the contracting process.

This information is necessary to help process your application and determine if your services, fit the needs of our provider network. Please select all values that tells us about you.

Authorization is required if you need to treat an Coordinated Care Health member prior to being contracted. Our Medical Management department will review the member’s needs with you and issue an Authorization as needed if a contracted provider is not available to provide the services. Medical Management does coordinate with our contracting department when a non-contracted provider receives an Authorization.

We will outreach to the contact person listed once a review of your data is completed. If you have any questions or are in need of additional information, please contact the Contracting Department at CONTRACTING@coordinatedcarehealth.com.