Contract Request Form

Thank you for your interest in joining the PA Health & Wellness provider network.

We are excited that you have selected PA Health & Wellness' provider network as your network of choice.

To get started, please complete the form below and someone from our Network Development team will respond back to you within two weeks. If we have a network need for your specialty or geographic area we will send you a packet which includes information required for credentialing. Please note that the plan is unable to approve all contract requests, but will keep them on file as network needs change often.

For all other Provider questions, please contact information@PAHealthWellness.com.
 

Required fields are marked with an asterisk (*)

Contact Information





Provider Information







Provider Identification Numbers







Product Option *
Please check all that apply.

If LTSS (Long Term Support and Services) was selected above, what type of service(s)are provided?
Please check all that apply.

 
Please attach your W-9 Form using the "Choose File" button