Join Our Network - Newly Contracted

What is the provider type of your contract request? *

Solo Group Facility/Agency

Tracking Number * Please provide the Tracking Number that you received in an email with your Provider Agreement.

Practice State *

Tax ID * Please do not use dashes ("-")

Provider First Name *

Provider Last Name *

Individual NPI *

Individual Taxonomy *

CAQH Number * A CAQH Profile is required to be credentialed with us. Please visit proview.caqh.org to confirm your CAQH Profile is current, recently attested, and approved for Cenpatico to view.

Individual Medicaid

Individual Medicare

Organization Medicaid

Organization Medicare

Contact Name *

Contact Phone *

Contact Email *

Provider Email *

Credentialing Checklist *

Provider Agreement *

W9 *

Facility Application *

Facility Roster *

Provider Specialty Profile *

Disclosure of Ownership Form *

Certificate of Insurance *

Group Attestation *

Proof of Enrollment with Medi-Cal or your DHCS 6208 Medi-Cal Provider Agreement form *

Additional Attachment 2 Attach licenses, accreditations, certifications, enrollment letters, etc...

Additional Attachment 3 Attach licenses, accreditations, certifications, enrollment letters, etc...

Additional Attachment 4 Attach licenses, accreditations, certifications, enrollment letters, etc...