Provider Contract Request

Provider Contract Request To request an application to join our network, please complete the form below. Completion of this application request form indicates your interest only. You may be contacted by a Provider Contract Specialist regarding next steps.

Note: Completion of this form is not part of the credentialing application for the network participation.

What is your Practice/Group Name?

What is the Practice/Provider Specialty?

Where is the Practice located (full address)?

What are your office hours?

Any additional languages spoken?

What is your NPI?

What is your Tax id#?

Are you currently enrolled with Medi-Cal Fee for Service?

Do you accept 100% of the Medi-Cal Fee Schedule?

Do you have offices in San Joaquin, Stanislaus, Alpine, Amador and El Dorado County?

Contact person’s name:

Contact person’s direct email:

Contact person’s direct phone number:

NOTE: Please allow 5-10 business days for a Contract Coordinator to reach out to you.