Please complete the information below as accurately as possible. There are three (3) pages total with the option to upload documents on the final page. Please email credentialing@michicare.org with questions about the form contents!
Provider Name:
Prefix
First Name
Middle Name
Last Name
Suffix
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
example@example.com
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Are you enrolled with CAQH?
*
Yes
No
I don't know
Do you have an NPI number?
*
Yes. I have an individual NPI number.
Yes. I have an individual and group NPI number.
No
I don't know
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Next
What BCBSM plans are you interested in contracting with?
BCBSM - Traditional
BCBSM - BCN
BCBSM - PPO
What CMS-Medicare plans are you interested in contracting with?
Medicaid - Champs
Blue Cross Community Blue
Meridian Health Plan of MI
Total Health Care
Molina
McLaren
UHC Community Plan
Priority Health
Aetna Medicaid
What other payers are you interested in contracting with?
Priority Health/Cigna
Aetna/Wellcare/Meritan - Cofinity
United Health Care - Optum/UMR
McLaren Health
Humana HAP
Payer not on the lists above? Tell us here:
Submit
Should be Empty: