Contract Request Form
Thank you for your interest in joining the PA Health and Wellness (PHW) provider network.
We are excited that you have selected PA Health and Wellness's provider network as your network of choice and look forward to an opportunity to partner in the service of our community.
At this time, PHW is not accepting Requests or Applications to Join Our Network when either a Primary or Secondary Specialty* as registered in PROMISe™ is listed below.
Application Exclusions List:
- Architectural Modifications (440)
- Assistive Technology (544)
- Chore Services (431)
- Enrollment (210)
- Environmental Accessibility Adaptions
- Home Delivered Meals (460)
- ISO - Fiscal/Employer Agent (541)
- Non-Emergency Transportation (267)
- Personal Assistance/Homecare services(s) (362)
- Personal Care - Agency (361)
- Personal Care - Individual (360)
- Personal Emergency Response System (025)
- PERS-Monthly Maintenance (028)
- Pest Eradication (501)
- Service Coordination (219)
- Telecare Services (029)
- Vehicle Modifications (255)
PHW appreciates your interest in joining our team of providers and asks for your understanding in the decision to close the Participating Provider Network to new Applications. The decision is aimed at matching the needs Participants with the availability of our existing Participating Providers, ensuring adequate Participant volume to support Provider staffing levels.
Changes in openness status for any specialty or service can occur at any time. In the event PHW’s Participants would benefit from additional In-Network Provider choice, the Exclusions List of closed services will be updated accordingly to accept applications by Providers with (i) sufficient existing capacity (either statewide or in specified counties) AND (ii) based upon physical location(s) or counties served as approved through registration with PROMISe™.
The PHW network of Participating Providers is open to accept applications for all other services not listed in the above Exclusions List* and as registered with PROMISe™ as the Primary Specialty.
To get started, please complete the form below and someone from our Network Development team will respond to you within two weeks. An application packet which includes information required for credentialing will be forthcoming.