Contract Request

Thank you for your interest in becoming a Contracted Provider with Martin’s Point Health Care.

Please complete the form below in its entirety and attach a copy of your W-9. We will perform an assessment and get back to you within 30 business days with a decision or to let you know if we need more information to complete the assessment.

Please note: A Provider/Group is not considered participating until a Contract is in place and if necessary, Providers have completed the credentialing process. Completing this form does not guarantee a Contract will be offered.


Contact
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Organization
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Details
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Have you previously contracted with Martin’s Point?

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Are you enrolled with and accept Medicare rates?

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Are you enrolled with and accept Tricare rates?

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