Contract Request Form

Thank you for your interest in becoming a Carolina Complete Health Network provider.

Please complete the below information and one of our team members will contact you within the next 5 business days.

We look forward to working with you to improve the health of the community.

Required fields are marked with an asterisk (*)

First Name *

Last Name *

Phone Number *

Email Address *

Entity Tax ID *

Entity Billing NPI *

Entity Medicaid Number

Legal Entity Name *

Attention – Name/Title *

Provider Mailing Address *

City *

State *

Zip *

County *

Provider Type * Primary Care Physician OB GYN Specialist Rural Health Clinic Facility

Facility Type *

W9 Form