Member/Panel Size on IHCP/Ambetter/Wellcare by Allwell/Wellcare Complete enrollment form will be applied to all contracted programs.
If you would like this panel size to vary by program please explain details in ‘Additional Comments’ field.
Please complete the provider forms below.
IHCP Ancillary Enrollment Form (PDF)
Items in the trash will be permanently removed after 30 days.
If there are 10 or more practitioners to be enrolled with a group contract request, please utilize the Practitioner Enrollment Spreadsheet.
Provider Location Listing (only Location Listing tab required for Ancillary requests)
BH Facility and Ancillary Demographic Info* (PDF)
If you requesting to participate in at least one of our Medicaid programs please complete the applicable practitioner form below (HHW, HCC, HIP).
IHCP Practitioner Enrollment Form (PDF)
If you requesting Commercial only programs complete the Ambetter/Wellcare by Allwell/Wellcare Complete PDF enrollment form.
Ambetter & Wellcare by Allwell Provider Enrollment Form (PDF)
The following documents are required depending on your specialty.
A Collaborative Agreement is required for the following Physician (Practitioner) types:
If you are a Behavioral Health Practitioner this form should be completed.
Behavioral Health Specialty Profile (PDF)
